Provider Demographics
NPI:1225063399
Name:DELA CRUZ, JEOFREY (PT)
Entity Type:Individual
Prefix:
First Name:JEOFREY
Middle Name:
Last Name:DELA CRUZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1514
Mailing Address - Country:US
Mailing Address - Phone:815-468-1401
Mailing Address - Fax:815-468-1409
Practice Address - Street 1:1052 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-9392
Practice Address - Country:US
Practice Address - Phone:815-468-1401
Practice Address - Fax:815-468-1409
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK11618-130Medicare UPIN