MEDICARE: MRS. ALFREDA GONZALEZ

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	2573-9130	MO

General Provider Information

NPI Number	:	1164551701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALFREDA GONZALEZ

Provider Business Mailing Address
First Line	:	114 W HICKORY ST
Second Line	:
City	:	EL DORADO SPRINGS
State	:	MO
Zip	:	64744-1402
Country	:	US
Telephone Number	:	417-876-6391
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 W HICKORY ST
Second Line	:
City	:	EL DORADO SPRINGS
State	:	MO
Zip	:	64744-1402
Country	:	US
Telephone Number	:	417-876-6391
Fax Number	:

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

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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