Basic Information
| Provider Information | |||||||||
| NPI: | 1194079913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 S.SANTA ANITA AVENUE | ||||||||
| Address2: | HUMAN RESOURCES/CHRISTINA GAMBOA | ||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
| FaxNumber: | 6262941079 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S SANTA ANITA AVE | ||||||||
| Address2: | HUMAN RESOURCES/CHRISTINA GAMBOA | ||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910063536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096222273 | ||||||||
| FaxNumber: | 9096226334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2012 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1194079913 | 05 | CA | MEDICAID |