Healthcare Provider Details

I. General information

NPI: 1659297851
Provider Name (Legal Business Name): ANDREW DEVIN GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14252 SCHLEISMAN RD STE 202
EASTVALE CA
92880-4026
US

IV. Provider business mailing address

4877 S ROSEMARY WAY
ONTARIO CA
91762-7580
US

V. Phone/Fax

Practice location:
  • Phone: 951-268-0794
  • Fax:
Mailing address:
  • Phone: 909-413-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number102461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: