Healthcare Provider Details

I. General information

NPI: 1104589779
Provider Name (Legal Business Name): IRVIN CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

487 WILLOW POND BLVD APT 104
MAINEVILLE OH
45039-7092
US

IV. Provider business mailing address

487 WILLOW POND BLVD APT 104
MAINEVILLE OH
45039-7092
US

V. Phone/Fax

Practice location:
  • Phone: 513-537-0433
  • Fax:
Mailing address:
  • Phone: 513-537-0433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: