Provider Demographics
NPI:1184219891
Name:CRUZ, KENNETH MARK NIEDO (PTA)
Entity Type:Individual
Prefix:
First Name:KENNETH MARK
Middle Name:NIEDO
Last Name:CRUZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 E WINDSOR RD APT 9
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2441
Mailing Address - Country:US
Mailing Address - Phone:323-384-8912
Mailing Address - Fax:
Practice Address - Street 1:1000 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3685
Practice Address - Country:US
Practice Address - Phone:818-243-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49797225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant