Healthcare Provider Details

I. General information

NPI: 1366998577
Provider Name (Legal Business Name): JOSE ADRIAN GONZALEZ B.L.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2573 STATE HIGHWAY 522
QUESTA NM
87556
US

IV. Provider business mailing address

2573 STATE HIGHWAY 522
QUESTA NM
87556
US

V. Phone/Fax

Practice location:
  • Phone: 575-586-0315
  • Fax: 575-586-0234
Mailing address:
  • Phone: 575-586-0315
  • Fax: 575-586-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: