1619306289 NPI number — MARK GONZALES LAADC-CA LCI10970318

Table of content: MARK GONZALES LAADC-CA LCI10970318 (NPI 1619306289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619306289 NPI number — MARK GONZALES LAADC-CA LCI10970318

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAADC-CA LCI10970318
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619306289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4023 W DOUGLAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VISALIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93291-4185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-691-0474
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4023 W DOUGLAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISALIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93291-4185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-691-0474
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  5465630291 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: LCI10970318 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 168767 . This is a "ADDICTION COUNSELOR CERTIFICATION BOARD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".