Healthcare Provider Details

I. General information

NPI: 1710359559
Provider Name (Legal Business Name): WONONO L. RUBIO CO 60576894
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 E 1ST ST
PORT ANGELES WA
98362-4012
US

IV. Provider business mailing address

933 E 1ST ST
PORT ANGELES WA
98362-4012
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-4432
  • Fax: 360-452-4599
Mailing address:
  • Phone: 360-452-4432
  • Fax: 360-452-4599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60576894
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: