Provider Demographics
NPI:1326620741
Name:GONZALEZ, OWEN (CPO)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 HENDERSON DR STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5297
Mailing Address - Country:US
Mailing Address - Phone:910-219-1455
Mailing Address - Fax:
Practice Address - Street 1:2680 HENDERSON DR STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5297
Practice Address - Country:US
Practice Address - Phone:910-219-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X
FLCO006226222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist