MEDICARE: LAURA CHRISTINE 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	171W00000X	Contractor

General Provider Information

NPI Number	:	1508041203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA CHRISTINE GONZALES

Provider Business Mailing Address
First Line	:	142 W BROADVIEW DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-2824
Country	:	US
Telephone Number	:	210-521-4244
Fax Number	:	210-265-5063

Provider Business Practice Location Address
First Line	:	142 W BROADVIEW DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-2824
Country	:	US
Telephone Number	:	210-521-4244
Fax Number	:	210-265-5063

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

Provider Enumeration Date	:	01/01/2008
Last Update Date	:	03/10/2010

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