Provider Demographics
NPI:1033535752
Name:CRUZ, CARLOS (COTA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1134
Mailing Address - Street 2:
Mailing Address - City:CARNATION
Mailing Address - State:WA
Mailing Address - Zip Code:98014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4509 B TOLT AVE
Practice Address - Street 2:
Practice Address - City:CARNATION
Practice Address - State:WA
Practice Address - Zip Code:98014
Practice Address - Country:US
Practice Address - Phone:407-760-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60416008224Z00000X
WAMA60499241225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant