Healthcare Provider Details

I. General information

NPI: 1174339220
Provider Name (Legal Business Name): KELLY GAYTAN RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 MASON MEADOWS DR NE
RIO RANCHO NM
87144-7581
US

IV. Provider business mailing address

3101 MASON MEADOWS DR NE
RIO RANCHO NM
87144-7581
US

V. Phone/Fax

Practice location:
  • Phone: 505-692-8420
  • Fax:
Mailing address:
  • Phone: 505-692-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: