Healthcare Provider Details

I. General information

NPI: 1023140670
Provider Name (Legal Business Name): SAMUEL GONZALES JR. BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

IV. Provider business mailing address

1201 N CRESCENT HEIGHTS BLVD #105
WEST HOLLYWOOD CA
90046-5046
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-1223
  • Fax: 310-837-6647
Mailing address:
  • Phone: 310-836-1223
  • Fax: 310-837-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: