Healthcare Provider Details

I. General information

NPI: 1548937832
Provider Name (Legal Business Name): JOAQUIN EMILIO CRUZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 07/22/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS GEORGE WASHINGTON (CVN 73) CVN 73, UNIT 100148, 1
FPO AE
09550
US

IV. Provider business mailing address

26054 MANZANITA ST
MURRIETA CA
92563-6317
US

V. Phone/Fax

Practice location:
  • Phone: 757-534-3448
  • Fax:
Mailing address:
  • Phone: 813-760-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: