Provider Demographics
NPI:1194550889
Name:GONZALEZ, ANTONIO JOSE LUIS
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:JOSE LUIS
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 CALLE ARIKARA
Mailing Address - Street 2:
Mailing Address - City:RIO RICO
Mailing Address - State:AZ
Mailing Address - Zip Code:85648-2900
Mailing Address - Country:US
Mailing Address - Phone:520-338-5556
Mailing Address - Fax:
Practice Address - Street 1:101 S LA CANADA DR STE 23
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-2662
Practice Address - Country:US
Practice Address - Phone:254-338-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT27987225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist