=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285422147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. FERNANDO ANDRES GONZALEZ GONZALEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2025
-----------------------------------------------------
Last Update Date | 05/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6285 MINTON RD NE
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-3008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-306-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1394 DUNLAWTON AVE APT 503
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-4761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-420-8048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH15460
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------