Provider Demographics
NPI:1871329888
Name:RUIZ, JOHN R (RN, BSN, PHN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:RUIZ
Suffix:
Gender:M
Credentials:RN, BSN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 ROCKCRESS LN
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-1260
Mailing Address - Country:US
Mailing Address - Phone:909-771-4103
Mailing Address - Fax:
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:909-758-0358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95304484163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse