Healthcare Provider Details

I. General information

NPI: 1003759879
Provider Name (Legal Business Name): SAMUEL GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 N BROADWAY STE 200
LOS ANGELES CA
90031-2803
US

IV. Provider business mailing address

3303 N BROADWAY STE 200
LOS ANGELES CA
90031-2803
US

V. Phone/Fax

Practice location:
  • Phone: 323-478-8200
  • Fax:
Mailing address:
  • Phone: 323-478-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: