=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912199233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLIP RUIZ, LATINA MEDICAL CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2007
-----------------------------------------------------
Last Update Date | 02/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1234 E FLORENCE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90001-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-583-9544
-----------------------------------------------------
Fax | 323-583-9546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1234 E FLORENCE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90001-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-583-9544
-----------------------------------------------------
Fax | 323-583-9546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PHILLIP ADRIAN RUIZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-359-9204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | PA16956
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | NP11421
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A44599
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------