MEDICARE: GONZALES FAMILY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	6211	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32-7099	OTHER	NM	MEDICARE LEGACY NUMBER

General Provider Information

NPI Number	:	1043324221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONZALES FAMILY, INC

Provider Business Mailing Address
First Line	:	1118 NATIONAL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4025
Country	:	US
Telephone Number	:	505-425-1538
Fax Number	:	505-425-7682

Provider Business Practice Location Address
First Line	:	1118 NATIONAL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4025
Country	:	US
Telephone Number	:	505-425-1538
Fax Number	:	505-425-7682

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MAXINE E GONZALES
Credential	:
Telephone Number	:	505-425-1538

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	11/09/2007

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Directions to “GONZALES FAMILY, INC ” Practice Location

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