Healthcare Provider Details

I. General information

NPI: 1215473152
Provider Name (Legal Business Name): MONIQUE RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E MAIN ST SUITE 600
OTHELLO WA
99344-1146
US

IV. Provider business mailing address

425 E MAIN ST SUITE 600
OTHELLO WA
99344-1146
US

V. Phone/Fax

Practice location:
  • Phone: 509-488-5611
  • Fax: 509-488-0166
Mailing address:
  • Phone: 509-488-5611
  • Fax: 509-488-0166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCG 60713511
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: