Provider Demographics
NPI:1871336768
Name:DE LA CRUZ, IVAN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2535
Mailing Address - Country:US
Mailing Address - Phone:850-716-2547
Mailing Address - Fax:
Practice Address - Street 1:1304 ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2535
Practice Address - Country:US
Practice Address - Phone:850-716-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer