Healthcare Provider Details

I. General information

NPI: 1417194754
Provider Name (Legal Business Name): MARIBEL VISTA DELA CRUZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 SPRINGVILLE ROAD SUITE 104
BIRMINGHAM AL
35215
US

IV. Provider business mailing address

156 DESCHLER BOULEVARD
CLAYTON NJ
08312
US

V. Phone/Fax

Practice location:
  • Phone: 180-085-4458
  • Fax:
Mailing address:
  • Phone: 215-847-9547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberJ1-0002151
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: