Provider Demographics
NPI:1811278245
Name:CRUZ AZUL OF WPB
Entity type:Organization
Organization Name:CRUZ AZUL OF WPB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-201-4016
Mailing Address - Street 1:6294 18TH ST S
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BCH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-5419
Mailing Address - Country:US
Mailing Address - Phone:561-201-4016
Mailing Address - Fax:
Practice Address - Street 1:6294 18TH ST S
Practice Address - Street 2:
Practice Address - City:WEST PALM BCH
Practice Address - State:FL
Practice Address - Zip Code:33415-5419
Practice Address - Country:US
Practice Address - Phone:561-201-4016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLE91892208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1891785994OtherCOMERCIAL INSURANCES PPO HMO