MEDICARE: JERIMI GONZALES

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	172A00000X	Driver

General Provider Information

NPI Number	:	1053789594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERIMI GONZALES

Provider Business Mailing Address
First Line	:	5160 VILLAGE CREEK DR STE 200
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4423
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5160 VILLAGE CREEK DR STE 200
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4423
Country	:	US
Telephone Number	:	972-248-3553
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	09/14/2015

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Directions to “ JERIMI GONZALES ” Practice Location

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