=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104002187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2008
-----------------------------------------------------
Last Update Date | 01/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1113 CLEMENTE ST SW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87121-8017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-839-7152
-----------------------------------------------------
Fax | 505-839-1241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1113 CLEMENTE ST SW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87121-8017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-839-7152
-----------------------------------------------------
Fax | 505-839-1241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL MANAGER
-----------------------------------------------------
Name | MRS. DEBORAH ANN ROARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-839-7152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 79930387
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------