Healthcare Provider Details

I. General information

NPI: 1245426204
Provider Name (Legal Business Name): JEIDALYS GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 2 BOX 11671
MOCA PR
00676-9823
US

IV. Provider business mailing address

HC 2 BOX 11671
MOCA PR
00676-9823
US

V. Phone/Fax

Practice location:
  • Phone: 787-877-0110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number4160
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: