Healthcare Provider Details

I. General information

NPI: 1700025574
Provider Name (Legal Business Name): SEBASTIAN ANDREW GONZALES III D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 W KATELLA AVE
ORANGE CA
92867
US

IV. Provider business mailing address

1525 MESA VERDE DR E STE 108
COSTA MESA CA
92626-5221
US

V. Phone/Fax

Practice location:
  • Phone: 714-392-6482
  • Fax:
Mailing address:
  • Phone: 714-502-4243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number31137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: