Healthcare Provider Details

I. General information

NPI: 1205477445
Provider Name (Legal Business Name): RENEE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2019
Last Update Date: 09/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8304 NW 39TH EXPY
BETHANY OK
73008-3011
US

IV. Provider business mailing address

PO BOX 263
BETHANY OK
73008-0263
US

V. Phone/Fax

Practice location:
  • Phone: 405-787-4434
  • Fax:
Mailing address:
  • Phone: 405-787-4434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1199
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: