Basic Information
| Provider Information | |||||||||
| NPI: | 1497973275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | LYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 SYCAMORE LN | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906211685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124511148 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27240 HAGGERTY RD | ||||||||
| Address2: | E-15 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483315716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
| FaxNumber: | 8669920900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| 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 | 225100000X | 32828 | CA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | IL | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.