Provider Demographics
NPI:1205285616
Name:CRUZ, VINCENT RODEO
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:RODEO
Last Name: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 1:3602 S W S YOUNG DR
Mailing Address - Street 2:APT 221
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-2942
Mailing Address - Country:US
Mailing Address - Phone:773-490-5728
Mailing Address - Fax:
Practice Address - Street 1:810 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-2222
Practice Address - Country:US
Practice Address - Phone:254-939-1876
Practice Address - Fax:254-933-7706
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1239220225100000X
NCP14637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist