Healthcare Provider Details

I. General information

NPI: 1689061996
Provider Name (Legal Business Name): ANTONIO CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2939 S HAVERHILL ROAD
WPB FL
33415
US

IV. Provider business mailing address

7936 AMBLESIDE WAY
LAKE WORTH FL
33467
US

V. Phone/Fax

Practice location:
  • Phone: 561-641-3130
  • Fax: 561-964-6178
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19014
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: