MEDICARE: MR. GONZALO REMULLA II

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	225100000X	Physical Therapist	2005000219	MO

General Provider Information

NPI Number	:	1861688210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GONZALO REMULLA II

Provider Business Mailing Address
First Line	:	1500 N OAKLAND AVE
Second Line	:
City	:	BOLIVAR
State	:	MO
Zip	:	65613-3011
Country	:	US
Telephone Number	:	417-328-6252
Fax Number	:	417-328-6242

Provider Business Practice Location Address
First Line	:	750 W COOPER ST
Second Line	:
City	:	BUFFALO
State	:	MO
Zip	:	65622-8662
Country	:	US
Telephone Number	:	417-345-5413
Fax Number	:	417-345-8674

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

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	09/19/2007

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Directions to “ MR. GONZALO REMULLA II ” Practice Location

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