Provider Demographics
NPI:1750059051
Name:DE LA CRUZ, BENJAMIN EDWARD
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
Last Name:DE LA CRUZ
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 1:50 HORGAN AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3645
Mailing Address - Country:US
Mailing Address - Phone:650-796-1884
Mailing Address - Fax:
Practice Address - Street 1:50 HORGAN AVE APT 9
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3645
Practice Address - Country:US
Practice Address - Phone:650-796-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer