MEDICARE: MR. GUILLERMO GONZALEZ I CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	17-085-4043	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780293068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GUILLERMO GONZALEZ I CORP

Provider Business Mailing Address
First Line	:	1037 NE PINE ISLAND LN
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2176
Country	:	US
Telephone Number	:	305-680-6865
Fax Number	:

Provider Business Practice Location Address
First Line	:	1037 NE PINE ISLAND LN
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2176
Country	:	US
Telephone Number	:	305-680-6865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2020
Last Update Date	:	07/23/2020

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