Provider Demographics
NPI:1255682027
Name:GONZALEZ RECOVERY RESIDENCES, INC.
Entity Type:Organization
Organization Name:GONZALEZ RECOVERY RESIDENCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:772-633-1097
Mailing Address - Street 1:1601 OCEAN DR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2252
Mailing Address - Country:US
Mailing Address - Phone:772-766-0465
Mailing Address - Fax:772-231-4220
Practice Address - Street 1:1401 N PICKETT ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1401
Practice Address - Country:US
Practice Address - Phone:772-633-1097
Practice Address - Fax:772-581-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA348324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility