Healthcare Provider Details

I. General information

NPI: 1972320570
Provider Name (Legal Business Name): MADELINE GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 INDIANA AVE STE 140
RIVERSIDE CA
92506-4266
US

IV. Provider business mailing address

8432 MAGNOLIA AVE # CMB2114
RIVERSIDE CA
92504-3297
US

V. Phone/Fax

Practice location:
  • Phone: 951-291-8770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: