Healthcare Provider Details

I. General information

NPI: 1477907574
Provider Name (Legal Business Name): BRYANT CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 DEBBIE DR
MARION TX
78124-1641
US

IV. Provider business mailing address

1123 DEBBIE DR
MARION TX
78124-1641
US

V. Phone/Fax

Practice location:
  • Phone: 210-324-5988
  • Fax:
Mailing address:
  • Phone: 210-324-5988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT036300
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: