Healthcare Provider Details

I. General information

NPI: 1669865382
Provider Name (Legal Business Name): ANDRE CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

7201 S SEPULVEDA BLVD
LOS ANGELES CA
90045-1514
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number708797
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: