Healthcare Provider Details

I. General information

NPI: 1982983110
Provider Name (Legal Business Name): MANUEL DELA CRUZ MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MOUNT VERNON AVE
BAKERSFIELD CA
93306-4018
US

IV. Provider business mailing address

9941 N SEDONA CIR
FRESNO CA
93720-5410
US

V. Phone/Fax

Practice location:
  • Phone: 661-326-2715
  • Fax:
Mailing address:
  • Phone: 559-314-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number749551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: