=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306010939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH SAMUEL RUIS II ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2008
-----------------------------------------------------
Last Update Date | 04/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 E MACCLENNY AVE SUITE A
-----------------------------------------------------
City | MACCLENNY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32063-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-316-9050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 86
-----------------------------------------------------
City | MACCLENNY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32063-0086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-316-9050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AL 1600
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------