Provider Demographics
NPI:1215707757
Name:CROSS, SPENCER
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:CROSS
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 1:80175 AVENUE 52 APT 711
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-7951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34275 MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2701
Practice Address - Country:US
Practice Address - Phone:442-305-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA725209164X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No164X00000XNursing Service ProvidersLicensed Vocational Nurse