Healthcare Provider Details

I. General information

NPI: 1871645036
Provider Name (Legal Business Name): MR. AGUSTIN G. CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 E KINGS CANYON RD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

2077 E RUSH AVE
FRESNO CA
93720-4716
US

V. Phone/Fax

Practice location:
  • Phone: 559-453-4099
  • Fax:
Mailing address:
  • Phone: 559-875-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: