Provider Demographics
NPI:1790565539
Name:GONZALEZ, ALFONSO
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
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 1:61003 LUCERNE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92561-3665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1341 N ESCONDIDO BLVD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2507
Practice Address - Country:US
Practice Address - Phone:760-747-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268940164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse