Healthcare Provider Details

I. General information

NPI: 1598517237
Provider Name (Legal Business Name): MARIELENA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 N THOMPSON ST
HEMET CA
92543-4311
US

IV. Provider business mailing address

258 N THOMPSON ST
HEMET CA
92543-4311
US

V. Phone/Fax

Practice location:
  • Phone: 951-288-5873
  • Fax:
Mailing address:
  • Phone: 951-288-5873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-BEWYHP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: