Healthcare Provider Details

I. General information

NPI: 1780473926
Provider Name (Legal Business Name): WILLIE CROMER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8175 LIMONITE AVE STE A
RIVERSIDE CA
92509-6120
US

IV. Provider business mailing address

8175 LIMONITE AVE STE A
RIVERSIDE CA
92509-6120
US

V. Phone/Fax

Practice location:
  • Phone: 951-370-7033
  • Fax: 951-370-7034
Mailing address:
  • Phone: 951-370-7033
  • Fax: 951-370-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: