Provider Demographics
NPI:1881377752
Name:EDWARDS-CRUZ, TAMARA D (BUSINESS OWNER)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:D
Last Name:EDWARDS-CRUZ
Suffix:
Gender:F
Credentials:BUSINESS OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 ARGYLE FOREST BLVD
Mailing Address - Street 2:STE21 #153
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244
Mailing Address - Country:US
Mailing Address - Phone:904-861-6686
Mailing Address - Fax:
Practice Address - Street 1:2489 W 30TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-3407
Practice Address - Country:US
Practice Address - Phone:904-607-6124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLE363804748750172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver