Provider Demographics
NPI:1104531037
Name:DELACRUZ, ROMAN
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:DELACRUZ
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 1:5739 28TH ST
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-2002
Mailing Address - Country:US
Mailing Address - Phone:951-407-6659
Mailing Address - Fax:
Practice Address - Street 1:5739 28TH ST
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-2002
Practice Address - Country:US
Practice Address - Phone:951-407-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver