=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972907509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SELINA RUIZ L.A.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2014
-----------------------------------------------------
Last Update Date | 10/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 S RACE ST
-----------------------------------------------------
City | EVERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76140-5216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-568-5276
-----------------------------------------------------
Fax | 817-568-5278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7224 ROUTT ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76112-7238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-475-1702
-----------------------------------------------------
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 | AT5508
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------