Healthcare Provider Details

I. General information

NPI: 1073790168
Provider Name (Legal Business Name): MICHELE DELA CRUZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 MARENGO AVE
LA MESA CA
91942-2408
US

IV. Provider business mailing address

1451 BRABHAM ST APT 909
EL CAJON CA
92019-4480
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-0281
  • Fax:
Mailing address:
  • Phone: 619-249-6685
  • Fax: 619-825-5820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 4703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: