Provider Demographics
NPI:1386377729
Name:CRUZ LANDA, PABLO DE JESUS
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:DE JESUS
Last Name:CRUZ LANDA
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 1:2014 MABURY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-7149
Mailing Address - Country:US
Mailing Address - Phone:714-909-5581
Mailing Address - Fax:
Practice Address - Street 1:13876 HARBOR BLVD STE 3B
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4029
Practice Address - Country:US
Practice Address - Phone:714-909-5817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA7604227172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver