=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689697591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALDINE GONZALEZ PABLO RPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 SANTA ROSA RD
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-7101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-388-1511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15011 BLACKHAWK ST
-----------------------------------------------------
City | MISSION HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91345-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-943-8972
-----------------------------------------------------
Fax | 818-838-7253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PT27758
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------