Healthcare Provider Details

I. General information

NPI: 1588471106
Provider Name (Legal Business Name): JOSE EDGARDO GONZALEZ CRUZ IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5019 GREEN BLUFF CT
SUMMERVILLE SC
29485-9327
US

IV. Provider business mailing address

5019 GREEN BLUFF CT
SUMMERVILLE SC
29485-9327
US

V. Phone/Fax

Practice location:
  • Phone: 787-478-1112
  • Fax:
Mailing address:
  • Phone: 787-478-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: