Provider Demographics
NPI:1598319139
Name:GONZALES, BERNARDO BAUTISTA JR
Entity Type:Individual
Prefix:
First Name:BERNARDO
Middle Name:BAUTISTA
Last Name:GONZALES
Suffix:JR
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 1:11643 CENTRALIA ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-1322
Mailing Address - Country:US
Mailing Address - Phone:661-418-4611
Mailing Address - Fax:
Practice Address - Street 1:11643 CENTRALIA ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90715-1322
Practice Address - Country:US
Practice Address - Phone:661-418-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider