Healthcare Provider Details

I. General information

NPI: 1801816723
Provider Name (Legal Business Name): CONSUELO MERCADO CRUZ MED TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BEVER GRADE
LAPWAI ID
83540
US

IV. Provider business mailing address

PO BOX 367
LAPWAI ID
83540-0367
US

V. Phone/Fax

Practice location:
  • Phone: 208-843-2271
  • Fax: 208-843-2658
Mailing address:
  • Phone: 208-843-2271
  • Fax: 208-843-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number1416664
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: