Provider Demographics
NPI:1093909459
Name:DE LA CRUZ, HUMBERTO SR
Entity Type:Individual
Prefix:MR
First Name:HUMBERTO
Middle Name:
Last Name:DE LA CRUZ
Suffix:SR
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 1:120 W WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-1629
Mailing Address - Country:US
Mailing Address - Phone:267-297-6848
Mailing Address - Fax:267-343-3796
Practice Address - Street 1:120 W WYOMING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-1629
Practice Address - Country:US
Practice Address - Phone:267-297-6848
Practice Address - Fax:267-343-3796
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health