MEDICARE: MR. RUBEN R RODIS JR.

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	310400000X	Assisted Living Facility	AL7402H	AZ

General Provider Information

NPI Number	:	1871229161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUBEN R RODIS JR.

Provider Business Mailing Address
First Line	:	15550 W CAMERON DR
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85379-1055
Country	:	US
Telephone Number	:	623-234-8655
Fax Number	:	623-234-1335

Provider Business Practice Location Address
First Line	:	15550 W CAMERON DR
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85379-1055
Country	:	US
Telephone Number	:	623-234-8655
Fax Number	:	623-234-1335

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

Provider Enumeration Date	:	07/28/2022
Last Update Date	:	07/28/2022

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