Healthcare Provider Details

I. General information

NPI: 1811278245
Provider Name (Legal Business Name): CRUZ AZUL OF WPB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6294 18TH ST S
WEST PALM BCH FL
33415-5419
US

IV. Provider business mailing address

6294 18TH ST S
WEST PALM BCH FL
33415-5419
US

V. Phone/Fax

Practice location:
  • Phone: 561-201-4016
  • Fax:
Mailing address:
  • Phone: 561-201-4016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberLE91892
License Number StateFL

VIII. Authorized Official

Name: DACHA CRUZ
Title or Position: PRESIDENT
Credential:
Phone: 561-201-4016