MEDICARE: GONSTEAD PHYSICAL MEDICINE PC

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	111N00000X	Chiropractor	5303	AZ

General Provider Information

NPI Number	:	1316163751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONSTEAD PHYSICAL MEDICINE PC

Provider Business Mailing Address
First Line	:	2735 W UNION HILLS DR
Second Line	:	SUITE 102
City	:	PHOENIX
State	:	AZ
Zip	:	85027-5033
Country	:	US
Telephone Number	:	602-973-1630
Fax Number	:	602-973-1667

Provider Business Practice Location Address
First Line	:	2735 W UNION HILLS DR
Second Line	:	SUITE 102
City	:	PHOENIX
State	:	AZ
Zip	:	85027-5033
Country	:	US
Telephone Number	:	602-973-1630
Fax Number	:	602-973-1667

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. JOSE LARA
Credential	:
Telephone Number	:	602-973-1630

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	06/17/2019

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Directions to “GONSTEAD PHYSICAL MEDICINE PC ” Practice Location

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