Basic Information
| Provider Information | |||||||||
| NPI: | 1023140670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 N CRESCENT HEIGHTS BLVD | ||||||||
| Address2: | #105 | ||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900465046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108361223 | ||||||||
| FaxNumber: | 3108376647 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 MOTOR AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900343710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108361223 | ||||||||
| FaxNumber: | 3108376647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.