1306157532 NPI number — MARILYN CAVITE CRUZ-ROSAL PT,DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306157532 NPI number — MARILYN CAVITE CRUZ-ROSAL PT,DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRUZ-ROSAL
Provider First Name:
MARILYN
Provider Middle Name:
CAVITE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT,DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRUZ
Provider Other First Name:
MARILYN
Provider Other Middle Name:
CAVITE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306157532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16089 POPPYSEED CIR
Provider Second Line Business Mailing Address:
SUITE 2008
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33484-6314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-496-7993
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
386 CLUBHOUSE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60490-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-838-0907
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  030347 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070019010 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C620-5438-0877 . This is a "IL DRIVER'S LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 070019010 . This is a "PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 586678724 . This is a "STATE IDENTIFICATION CARD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".