Provider Demographics
NPI:1053723494
Name:RUIZ, ROBERTO CARRILLO (LAT)
Entity type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:CARRILLO
Last Name:RUIZ
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N PEBBLE CREEK PKWY APT 2090
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-9032
Mailing Address - Country:US
Mailing Address - Phone:216-973-7794
Mailing Address - Fax:
Practice Address - Street 1:4200 N PEBBLE CREEK PKWY APT 2090
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9032
Practice Address - Country:US
Practice Address - Phone:216-973-7794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10122255A2300X
OHAT.0035682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer