Healthcare Provider Details

I. General information

NPI: 1124594726
Provider Name (Legal Business Name): EDNIE JAFFED RUIZ SR. MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO. JAGUEY CARR 411 KM 4.9
AGUADA PR
00602-0060
US

IV. Provider business mailing address

HC 60 BOX 15262
AGUADA PR
00602-9268
US

V. Phone/Fax

Practice location:
  • Phone: 787-624-9258
  • Fax:
Mailing address:
  • Phone: 787-624-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14406
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: