Healthcare Provider Details

I. General information

NPI: 1861122194
Provider Name (Legal Business Name): JUAN R CRUZ ALONSO CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MARYLAND FARMS STE 200
BRENTWOOD TN
37027-5780
US

IV. Provider business mailing address

3 MARYLAND FARMS STE 200
BRENTWOOD TN
37027-5780
US

V. Phone/Fax

Practice location:
  • Phone: 800-348-4565
  • Fax: 888-203-4247
Mailing address:
  • Phone: 800-348-4565
  • Fax: 888-203-4247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number15-147
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: