Provider Demographics
NPI:1992921324
Name:GONZALES, CARLO MAGNO (PT)
Entity type:Individual
Prefix:
First Name:CARLO
Middle Name:MAGNO
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N 2ND ST APT G50
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-2021
Mailing Address - Country:US
Mailing Address - Phone:870-931-6789
Mailing Address - Fax:
Practice Address - Street 1:810 JOE BROOKS DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4133
Practice Address - Country:US
Practice Address - Phone:870-931-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist