Basic Information
| Provider Information | |||||||||
| NPI: | 1679926646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920680032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628268000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 32245 MISSION TRL STE D4 | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925304528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516741561 | ||||||||
| FaxNumber: | 9516745300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2016 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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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 | 152W00000X | 33482 | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1679926646 | 01 | CA | OPTOMETRY | OTHER |