MEDICARE: CRUZ PERSONAL CARE HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	149535	TX

General Provider Information

NPI Number	:	1912489642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRUZ PERSONAL CARE HOME, LLC

Provider Business Mailing Address
First Line	:	2603 W SOUTHCROSS BLVD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78211-1850
Country	:	US
Telephone Number	:	512-657-9262
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 COUNTY ROAD 664
Second Line	:
City	:	DEVINE
State	:	TX
Zip	:	78016-4685
Country	:	US
Telephone Number	:	210-977-9178
Fax Number	:	210-977-9205

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VIRGINIA MINDIETA
Credential	:
Telephone Number	:	512-657-9262

Provider Enumeration Date	:	08/29/2018
Last Update Date	:	08/29/2018

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