Healthcare Provider Details

I. General information

NPI: 1164551701
Provider Name (Legal Business Name): MRS. ALFREDA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W HICKORY ST
EL DORADO SPRINGS MO
64744-1402
US

IV. Provider business mailing address

114 W HICKORY ST
EL DORADO SPRINGS MO
64744-1402
US

V. Phone/Fax

Practice location:
  • Phone: 417-876-6391
  • Fax:
Mailing address:
  • Phone: 417-876-6391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2573-9130
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: