Provider Demographics
NPI:1154016582
Name:REYES MERCADO, RUBY
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:REYES MERCADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 W AVENUE J STE 300
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2944
Mailing Address - Country:US
Mailing Address - Phone:661-341-3495
Mailing Address - Fax:
Practice Address - Street 1:1216 W AVENUE J STE 300
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2944
Practice Address - Country:US
Practice Address - Phone:661-341-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CAMPSS-UTGELN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker