Provider Demographics
NPI:1942096201
Name:DE LA CRUZ, AGUSTIN ELIAS
Entity type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:ELIAS
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 CAMINO ELEVADO
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2430
Mailing Address - Country:US
Mailing Address - Phone:619-629-5893
Mailing Address - Fax:
Practice Address - Street 1:4455 MURPHY CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4379
Practice Address - Country:US
Practice Address - Phone:619-629-5893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician