Healthcare Provider Details

I. General information

NPI: 1679600829
Provider Name (Legal Business Name): ANTONIO RAY GONZALES D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 11/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 LAMBERT ST
NILES MI
49120-3413
US

IV. Provider business mailing address

920 LAMBERT ST
NILES MI
49120-3413
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-4200
  • Fax: 269-262-0943
Mailing address:
  • Phone: 269-684-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001868A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2301008841
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2301008841
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301008841
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: