Healthcare Provider Details

I. General information

NPI: 1124399613
Provider Name (Legal Business Name): CLEOFE SECULAR CRUZ R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 E 17TH ST
BROOKLYN NY
11229-1259
US

IV. Provider business mailing address

9705 HORACE HARDING EXPY 14-O
CORONA NY
11368-4157
US

V. Phone/Fax

Practice location:
  • Phone: 718-998-0200
  • Fax:
Mailing address:
  • Phone: 347-420-9452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number635507
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number635507
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: