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General NPI Number Information
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NPI Number | 1609945328
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Entity Type | Individual
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Provider Name | JOHN ANSEL CRUZ JIMENEZ PT
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Gender | Male
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 09/21/2018
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Provider Practice Location Address
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Address Line | 100 E MANANA BLVD UNIT 1
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City | CLOVIS
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State | NM
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Zip | 88101-3503
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Country | US
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Telephone | 575-366-5014
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Fax | 575-366-5015
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Provider Business Mailing Address
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Address Line | 100 E MANANA BLVD STE 1
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City | CLOVIS
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State | NM
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Zip | 88101-3503
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Country | US
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Telephone | 575-366-5014
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Fax | 575-366-5015
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 3209
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License Number State | NM
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Legacy Identifiers
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Identifier #1
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Identifier Code | 29880360
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Identifier Type | MEDICAID
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Identifier State | NM
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 29880360
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Identifier Type | MEDICAID
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Identifier State | NM
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Identifier Issuer |
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