Provider Demographics
NPI:1760506786
Name:GONZALEZ, MARIO G
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:G
Last Name:GONZALEZ
Suffix:
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 1:6236 WILLOWCREST AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3911
Mailing Address - Country:US
Mailing Address - Phone:213-706-7764
Mailing Address - Fax:
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:5TH FL
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-706-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner