Provider Demographics
NPI:1699188466
Name:TREVIZO, CRUZ JR
Entity Type:Individual
Prefix:
First Name:CRUZ
Middle Name:
Last Name:TREVIZO
Suffix:JR
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 1:2525 N GRANDVIEW AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1621
Mailing Address - Country:US
Mailing Address - Phone:432-550-4700
Mailing Address - Fax:
Practice Address - Street 1:710 E HOLLAND AVE STE 6
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-5007
Practice Address - Country:US
Practice Address - Phone:432-837-5918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4052871225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant