Provider Demographics
NPI:1598542037
Name:CRUZ-VILLANUEVA, JOSE RICARDO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:RICARDO
Last Name:CRUZ-VILLANUEVA
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 1:3400 N 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2411
Mailing Address - Country:US
Mailing Address - Phone:954-696-8221
Mailing Address - Fax:
Practice Address - Street 1:3400 N 72ND AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2411
Practice Address - Country:US
Practice Address - Phone:954-696-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17591224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant