Provider Demographics
NPI:1407107527
Name:DELA CRUZ, EDEFER ANONUEVO (RPT)
Entity Type:Individual
Prefix:MR
First Name:EDEFER
Middle Name:ANONUEVO
Last Name:DELA CRUZ
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 W VINCENT DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1061
Mailing Address - Country:US
Mailing Address - Phone:417-823-7854
Mailing Address - Fax:417-823-7854
Practice Address - Street 1:1514 W LARK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2270
Practice Address - Country:US
Practice Address - Phone:417-889-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006011989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist