Healthcare Provider Details

I. General information

NPI: 1962556605
Provider Name (Legal Business Name): JOSE A RUIZ CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 RIVERVIEW AVE
WAUKESHA WI
53188-3632
US

IV. Provider business mailing address

514 RIVERVIEW AVE
WAUKESHA WI
53188-3632
US

V. Phone/Fax

Practice location:
  • Phone: 262-548-7666
  • Fax: 262-548-7656
Mailing address:
  • Phone: 262-548-7666
  • Fax: 262-548-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number691-132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: