Healthcare Provider Details

I. General information

NPI: 1699471441
Provider Name (Legal Business Name): EARL DAVID CRUZ DUMALAOG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 S HARBOR BLVD
ANAHEIM CA
92805-5157
US

IV. Provider business mailing address

212 S KRAEMER BLVD UNIT 203
PLACENTIA CA
92870-6107
US

V. Phone/Fax

Practice location:
  • Phone: 714-635-8131
  • Fax:
Mailing address:
  • Phone: 909-610-0397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: