Healthcare Provider Details

I. General information

NPI: 1053866533
Provider Name (Legal Business Name): MR. JAVIER GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 E OLYMPIC BLVD
COMMERCE CA
90022-5147
US

IV. Provider business mailing address

333 S BEAUDRY AVE
LOS ANGELES CA
90017-1466
US

V. Phone/Fax

Practice location:
  • Phone: 323-543-2800
  • Fax:
Mailing address:
  • Phone: 213-241-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: