Healthcare Provider Details

I. General information

NPI: 1245110014
Provider Name (Legal Business Name): LUIS ALEJANDRO GONZALEZ GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3848 FAU BLVD STE 105
BOCA RATON FL
33431-6437
US

IV. Provider business mailing address

40 W LAKE PASS
NEWNAN GA
30263-4666
US

V. Phone/Fax

Practice location:
  • Phone: 561-997-5210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTT43736
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018118
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: