Healthcare Provider Details

I. General information

NPI: 1013289107
Provider Name (Legal Business Name): MIRIAN CRUZ CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A23 CALLE 1 URB SIERRA LINDA
BAYAMON PR
00957
US

IV. Provider business mailing address

1 RES SIERRA LINDA # URB A23 CALLE 1
BAYAMON PR
00957-2002
US

V. Phone/Fax

Practice location:
  • Phone: 787-367-6818
  • Fax:
Mailing address:
  • Phone: 787-367-6818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number8347
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: