Healthcare Provider Details

I. General information

NPI: 1760617161
Provider Name (Legal Business Name): SANDY RUIZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 RIVERSIDE DR W 4K70
NEW YORK NY
10032-1004
US

IV. Provider business mailing address

15900 RIVERSIDE DR W 4K70
NEW YORK NY
10032-1004
US

V. Phone/Fax

Practice location:
  • Phone: 646-305-2415
  • Fax: 212-795-7579
Mailing address:
  • Phone: 646-305-2415
  • Fax: 212-795-7579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number005933-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: