Healthcare Provider Details

I. General information

NPI: 1437528585
Provider Name (Legal Business Name): CARLOS CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date: 07/10/2022
Reactivation Date: 12/08/2022

III. Provider practice location address

15305 RAYEN ST
NORTH HILLS CA
91343-5117
US

IV. Provider business mailing address

15305 RAYEN ST
NORTH HILLS CA
91343-5117
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-3384
  • Fax:
Mailing address:
  • Phone: 818-894-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: