Healthcare Provider Details

I. General information

NPI: 1720803877
Provider Name (Legal Business Name): ROBERTO ANTONIO GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15354 LA SUBIDA DR
HACIENDA HEIGHTS CA
91745-4426
US

IV. Provider business mailing address

15354 LA SUBIDA DR
HACIENDA HEIGHTS CA
91745-4426
US

V. Phone/Fax

Practice location:
  • Phone: 626-210-5272
  • Fax:
Mailing address:
  • Phone: 626-210-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTCH201260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: