1750538807 NPI number — MS. IVYROSE GONZALES MOTR/L,ATC

Table of content: MS. IVYROSE GONZALES MOTR/L,ATC (NPI 1750538807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750538807 NPI number — MS. IVYROSE GONZALES MOTR/L,ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
IVYROSE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MOTR/L,ATC
Provider Gender Code:
F

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:
1750538807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12105 DAN PATCH RD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87123-2196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-350-3069
Provider Business Mailing Address Fax Number:
505-508-2305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2727 SAN PEDRO DR NE
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110-3364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-350-3069
Provider Business Practice Location Address Fax Number:
505-508-2305
Provider Enumeration Date:
08/20/2008

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 0805 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 93985312 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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