MEDICARE: JESSICA L RUIZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1265830749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA L RUIZ

Provider Business Mailing Address
First Line	:	11 WINDHAM LOOP APT 2EE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-5938
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 WINDHAM LOOP
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-5959
Country	:	US
Telephone Number	:	908-578-3952
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/19/2014

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Directions to “ JESSICA L RUIZ ” Practice Location

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