Provider Demographics
NPI:1912489642
Name:CRUZ PERSONAL CARE HOME, LLC
Entity Type:Organization
Organization Name:CRUZ PERSONAL CARE HOME, LLC
Other - Org Name:CRUZ PERSONAL CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MINDIETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-657-9262
Mailing Address - Street 1:2603 W SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78211-1850
Mailing Address - Country:US
Mailing Address - Phone:512-657-9262
Mailing Address - Fax:
Practice Address - Street 1:730 COUNTY ROAD 664
Practice Address - Street 2:
Practice Address - City:DEVINE
Practice Address - State:TX
Practice Address - Zip Code:78016-4685
Practice Address - Country:US
Practice Address - Phone:210-977-9178
Practice Address - Fax:210-977-9205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX149535310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility