Healthcare Provider Details

I. General information

NPI: 1518987783
Provider Name (Legal Business Name): JOSE A. GONZALEZ JR. DC DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WADING RIVER RD
CENTER MORICHES NY
11934-1107
US

IV. Provider business mailing address

164 WADING RIVER RD
CENTER MORICHES NY
11934-1107
US

V. Phone/Fax

Practice location:
  • Phone: 613-574-0239
  • Fax:
Mailing address:
  • Phone: 613-574-0239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX008699
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number037176
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: