Healthcare Provider Details

I. General information

NPI: 1750960340
Provider Name (Legal Business Name): CARON GEORGE GONZALEZ CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CARNEGIE LN APT 1
REDONDO BEACH CA
90278-3658
US

IV. Provider business mailing address

1732 AVIATION BLVD # 524
REDONDO BEACH CA
90278-2810
US

V. Phone/Fax

Practice location:
  • Phone: 718-541-9702
  • Fax:
Mailing address:
  • Phone: 718-541-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number68743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: