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General NPI Number Information
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NPI Number | 1255682027
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Entity Type | Organization
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Legal Business Name | GONZALEZ RECOVERY RESIDENCES, INC.
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Dates
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Enumeration Date | 09/20/2012
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Last Update Date | 09/20/2012
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Provider Practice Location Address
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Address Line | 1401 N PICKETT ST
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City | ALEXANDRIA
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State | VA
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Zip | 22304-1401
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Country | US
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Telephone | 772-633-1097
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Fax | 772-581-8101
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Provider Business Mailing Address
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Address Line | 1601 OCEAN DR
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City | VERO BEACH
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State | FL
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Zip | 32963-2252
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Country | US
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Telephone | 772-766-0465
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Fax | 772-231-4220
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MR. BORIS GONZALEZ
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Credential | PHD
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Telephone | 772-633-1097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 348
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License Number State | VA
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