Provider Demographics
NPI:1801199195
Name:GONZALES, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 TAHOE CIR APT A
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-5709
Mailing Address - Country:US
Mailing Address - Phone:951-663-2257
Mailing Address - Fax:
Practice Address - Street 1:2345 TAHOE CIR
Practice Address - Street 2:APT A
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-5709
Practice Address - Country:US
Practice Address - Phone:951-663-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2587840343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)