Basic Information
| Provider Information | |||||||||
| NPI: | 1407107527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELA CRUZ | ||||||||
| FirstName: | EDEFER | ||||||||
| MiddleName: | ANONUEVO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3853 W VINCENT DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658101061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178237854 | ||||||||
| FaxNumber: | 4178237854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 W LARK ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658102270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178891275 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2006011989 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.