Healthcare Provider Details

I. General information

NPI: 1780700252
Provider Name (Legal Business Name): ALVIN ANSELMO CRUZ BOMBASE RPT, CEAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 12/13/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24920 WALNUT ST
LOMITA CA
90717-1925
US

IV. Provider business mailing address

16630 S BROADWAY
GARDENA CA
90248-2716
US

V. Phone/Fax

Practice location:
  • Phone: 310-293-7416
  • Fax:
Mailing address:
  • Phone: 310-768-8155
  • Fax: 310-768-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28286
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number28286
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number28286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: