Provider Demographics
NPI:1811508252
Name:CRUZ, EPHRAIM
Entity type:Individual
Prefix:
First Name:EPHRAIM
Middle Name:
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 1:8027 CAMELLIA RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-3416
Mailing Address - Country:US
Mailing Address - Phone:757-227-1105
Mailing Address - Fax:757-214-6634
Practice Address - Street 1:8027 CAMELLIA RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-3416
Practice Address - Country:US
Practice Address - Phone:757-227-1105
Practice Address - Fax:757-214-6634
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320600000X, 320700000X, 343900000X, 347C00000X
VA29911320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA81-3347603Medicaid