Provider Demographics
NPI:1821703240
Name:KRUZICH, NICHOLAS FRED (CDAC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:FRED
Last Name:KRUZICH
Suffix:
Gender:M
Credentials:CDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-1720
Mailing Address - Country:US
Mailing Address - Phone:515-967-7502
Mailing Address - Fax:
Practice Address - Street 1:401 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-1720
Practice Address - Country:US
Practice Address - Phone:515-967-7502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA230119-001760Medicaid