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General NPI Number Information
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NPI Number | 1972944312
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Entity Type | Individual
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Provider Name | RANDY M GONZALES L.AC,LMT
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Gender | Male
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Dates
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Enumeration Date | 07/15/2013
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Last Update Date | 06/25/2015
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Provider Practice Location Address
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Address Line | 999 OLD MEDFORD AVE
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City | FARMINGVILLE
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State | NY
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Zip | 11738-2829
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Country | US
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Telephone | 631-875-7200
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Fax |
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Provider Business Mailing Address
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Address Line | 999 OLD MEDFORD AVE
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City | FARMINGVILLE
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State | NY
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Zip | 11738-2829
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Country | US
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Telephone | 631-875-7200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 005079-1
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License Number State | NY
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