Provider Demographics
NPI:1033730346
Name:DELA CRUZ, RODERICK BRIAN
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:BRIAN
Last Name:DELA 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 1:9428 69TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8111
Mailing Address - Country:US
Mailing Address - Phone:262-344-3892
Mailing Address - Fax:
Practice Address - Street 1:9428 69TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8111
Practice Address - Country:US
Practice Address - Phone:262-344-3892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI239454163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical