Basic Information
| Provider Information | |||||||||
| NPI: | 1104205699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LA CRUZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45550 GRACE ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922014610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603421233 | ||||||||
| FaxNumber: | 7603224554 | ||||||||
| Practice Location | |||||||||
| Address1: | 45550 GRACE ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922014610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603421233 | ||||||||
| FaxNumber: | 7603224554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2015 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CADTP#1483 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.