Provider Demographics
NPI:1689900201
Name:GONZALEZ, REFUGIO (DC)
Entity Type:Individual
Prefix:DR
First Name:REFUGIO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N FORD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1122
Mailing Address - Country:US
Mailing Address - Phone:323-262-9222
Mailing Address - Fax:
Practice Address - Street 1:400 N FORD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1122
Practice Address - Country:US
Practice Address - Phone:323-262-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28375OtherSTATE LICENSE
CAU99049Medicare UPIN