Provider Demographics
NPI:1609270891
Name:PHYLLIS NADINE GONZALES
Entity Type:Organization
Organization Name:PHYLLIS NADINE GONZALES
Other - Org Name:UNIVERSAL CHIROPRACTIC DR. P.NADINE GONZALES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS NADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC, BSN-RN
Authorized Official - Phone:505-946-7677
Mailing Address - Street 1:121 CAMINO ENCANTADO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1039
Mailing Address - Country:US
Mailing Address - Phone:505-946-7677
Mailing Address - Fax:505-986-1569
Practice Address - Street 1:219 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1926
Practice Address - Country:US
Practice Address - Phone:505-946-7677
Practice Address - Fax:505-986-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1318111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9408737OtherPRIVATE HEALTHCARE SYSTEM
NMNM00KL98OtherBLUE CROSS BLUE SHIELD NM
NM12395202OtherMULTIPLAN
NM11NR0400XOtherNUCC TAXONOMY
1821150756OtherNPI TYPE 1
OR876338000OtherREGENCE BCBS OREGON
NM5657319OtherFIRST HEALTH
NM12248763OtherCAQH
NM693017OtherACN GROUP