Provider Demographics
NPI:1730905621
Name:BARRUETA, AMANDA S
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:BARRUETA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 FERN PINE ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-1243
Mailing Address - Country:US
Mailing Address - Phone:818-210-8490
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:818-210-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner