Healthcare Provider Details

I. General information

NPI: 1508923905
Provider Name (Legal Business Name): ELISA F CRUZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 TEXAS BLVD STE 406 ATTENTION PT DEPT
TEXARKANA TX
75501-5113
US

IV. Provider business mailing address

1002 TEXAS BLVD STE 406 ATTENTION PT DEPT
TEXARKANA TX
75501-5113
US

V. Phone/Fax

Practice location:
  • Phone: 903-794-4196
  • Fax: 903-794-4198
Mailing address:
  • Phone: 903-794-4196
  • Fax: 903-794-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1080893
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: