Provider Demographics
NPI:1932410925
Name:CRUZ, EDWIN ALEXANDER
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:ALEXANDER
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 1:2594 INDUSTRY WAY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4015
Mailing Address - Country:US
Mailing Address - Phone:310-677-4070
Mailing Address - Fax:
Practice Address - Street 1:1300 S GRAND AVE STE C
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4402
Practice Address - Country:US
Practice Address - Phone:714-567-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84791101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health