Healthcare Provider Details

I. General information

NPI: 1053240408
Provider Name (Legal Business Name): SELENE GONZALEZ MAYNEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 30TH STREET RD LOT A35
GREELEY CO
80631-1021
US

IV. Provider business mailing address

1107 30TH STREET RD LOT A35 A35
GREELEY CO
80631-1021
US

V. Phone/Fax

Practice location:
  • Phone: 970-308-6336
  • Fax: 970-308-6336
Mailing address:
  • Phone: 970-308-6336
  • Fax: 970-308-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: