Healthcare Provider Details

I. General information

NPI: 1336628940
Provider Name (Legal Business Name): ROSALINDA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 MICHIGAN AVE
DETROIT MI
48210-3039
US

IV. Provider business mailing address

8272 CORNELL ST
TAYLOR MI
48180-2264
US

V. Phone/Fax

Practice location:
  • Phone: 313-963-2266
  • Fax: 313-963-2471
Mailing address:
  • Phone: 313-844-1473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: