Healthcare Provider Details

I. General information

NPI: 1912379868
Provider Name (Legal Business Name): EDWARD FRANCIS GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 AVONDALE DR
MYRTLE BEACH SC
29588-5404
US

IV. Provider business mailing address

165 AVONDALE DR
MYRTLE BEACH SC
29588-5404
US

V. Phone/Fax

Practice location:
  • Phone: 843-650-5684
  • Fax:
Mailing address:
  • Phone: 843-650-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3353
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: