MEDICARE: CARLOS GONZALEZ LMT

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	225700000X	Massage Therapist	020826	OH

General Provider Information

NPI Number	:	1073919460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS GONZALEZ LMT

Provider Business Mailing Address
First Line	:	1519 BURLINGTON RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1216
Country	:	US
Telephone Number	:	440-382-5005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1519 BURLINGTON RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1216
Country	:	US
Telephone Number	:	440-781-9237
Fax Number	:

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

Provider Enumeration Date	:	11/12/2014
Last Update Date	:	11/29/2017

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