MEDICARE: DESIREE DAWN RUIZ MENDOZA

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	374U00000X	Home Health Aide	92133	WV

General Provider Information

NPI Number	:	1871455600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE DAWN RUIZ MENDOZA

Provider Business Mailing Address
First Line	:	543 PAXTON RD
Second Line	:
City	:	GALLIPOLIS
State	:	OH
Zip	:	45631-8717
Country	:	US
Telephone Number	:	828-200-3710
Fax Number	:

Provider Business Practice Location Address
First Line	:	543 PAXTON RD
Second Line	:
City	:	GALLIPOLIS
State	:	OH
Zip	:	45631-8717
Country	:	US
Telephone Number	:	828-200-3710
Fax Number	:

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

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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