Provider Demographics
NPI:1417352188
Name:GONZALES, LUIS JIGGS (MPT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:JIGGS
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 N VERDUGO RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1219
Mailing Address - Country:US
Mailing Address - Phone:818-236-4833
Mailing Address - Fax:818-236-4835
Practice Address - Street 1:3600 N VERDUGO RD
Practice Address - Street 2:SUITE 300
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1219
Practice Address - Country:US
Practice Address - Phone:818-236-4833
Practice Address - Fax:818-236-4835
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 41833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist