Provider Demographics
NPI:1639624430
Name:DE LA CRUZ, VENNERY (PT)
Entity Type:Individual
Prefix:
First Name:VENNERY
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4971 LE CHALET BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-1418
Mailing Address - Country:US
Mailing Address - Phone:561-733-5590
Mailing Address - Fax:561-740-0714
Practice Address - Street 1:1100 S MAIN ST
Practice Address - Street 2:103
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-4910
Practice Address - Country:US
Practice Address - Phone:561-996-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIS289ZMedicare PIN