Healthcare Provider Details

I. General information

NPI: 1497040133
Provider Name (Legal Business Name): MRS. STEPHANIE J. GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 ALLSTON ST (LOCATION VARYS)
LOS ANGELES CA
90022
US

IV. Provider business mailing address

6112 ALLSTON ST
LOS ANGELES CA
90022
US

V. Phone/Fax

Practice location:
  • Phone: 213-858-2500
  • Fax: 323-724-1178
Mailing address:
  • Phone: 213-858-2500
  • Fax: 323-724-1178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: