Provider Demographics
NPI:1649818220
Name:BYRD CROSS, MATILDA ANN
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:ANN
Last Name:BYRD CROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 CHERRYTREE RD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8481
Mailing Address - Country:US
Mailing Address - Phone:909-644-3822
Mailing Address - Fax:
Practice Address - Street 1:1430 E COOLEY DR STE 111
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3944
Practice Address - Country:US
Practice Address - Phone:909-420-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker