Healthcare Provider Details

I. General information

NPI: 1982128765
Provider Name (Legal Business Name): BEN MAKANAMAIKALANI GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 HWY 314 SW
LOS LUNAS NM
87031-9600
US

IV. Provider business mailing address

535 HWY 314 SW
LOS LUNAS NM
87031-9600
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-0055
  • Fax:
Mailing address:
  • Phone: 505-866-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5114
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: