Healthcare Provider Details

I. General information

NPI: 1154551034
Provider Name (Legal Business Name): SOR INES CRUZ M.R.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4446 FOUR LAKES DR
MELBOURNE FL
32940-1247
US

IV. Provider business mailing address

4446 FOUR LAKES DR
MELBOURNE FL
32940-1247
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-1566
  • Fax:
Mailing address:
  • Phone: 321-253-1566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00815
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: