=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720097710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLEZ MEDICAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3670-72 NW 1 ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-394-8141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3670-72 NW 1 ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GEORGE E. GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-351-6191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME64804
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------