Healthcare Provider Details

I. General information

NPI: 1326620741
Provider Name (Legal Business Name): OWEN GONZALEZ CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 HENDERSON DR STE 3
JACKSONVILLE NC
28546-5297
US

IV. Provider business mailing address

2680 HENDERSON DR STE 3
JACKSONVILLE NC
28546-5297
US

V. Phone/Fax

Practice location:
  • Phone: 910-219-1455
  • Fax:
Mailing address:
  • Phone: 910-219-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCO006226
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: