Provider Demographics
NPI:1598592701
Name:DE LA CRUZ SEGURA, RAYNER (PTA)
Entity type:Individual
Prefix:
First Name:RAYNER
Middle Name:
Last Name:DE LA CRUZ SEGURA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-4448
Mailing Address - Country:US
Mailing Address - Phone:847-800-3504
Mailing Address - Fax:
Practice Address - Street 1:348 MAPLE LN
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-4448
Practice Address - Country:US
Practice Address - Phone:847-800-3504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist