Healthcare Provider Details

I. General information

NPI: 1134819709
Provider Name (Legal Business Name): SUSANA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E RINCON ST STE 219
CORONA CA
92879-1387
US

IV. Provider business mailing address

2622 CYPRESS ST
HEMET CA
92545-5304
US

V. Phone/Fax

Practice location:
  • Phone: 951-817-5328
  • Fax:
Mailing address:
  • Phone: 951-292-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: