Healthcare Provider Details

I. General information

NPI: 1497516546
Provider Name (Legal Business Name): JAMES GONZALES CORPORATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12208 MIRANDY CT NE
ALBUQUERQUE NM
87122-1274
US

IV. Provider business mailing address

12208 MIRANDY CT NE
ALBUQUERQUE NM
87122-1274
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-4579
  • Fax:
Mailing address:
  • Phone: 505-554-4579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES ORLANDO GONZALES
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 505-554-4579