Provider Demographics
NPI:1861688210
Name:REMULLA, GONZALO II
Entity Type:Individual
Prefix:MR
First Name:GONZALO
Middle Name:
Last Name:REMULLA
Suffix:II
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 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-328-6252
Mailing Address - Fax:417-328-6242
Practice Address - Street 1:750 W COOPER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-8662
Practice Address - Country:US
Practice Address - Phone:417-345-5413
Practice Address - Fax:417-345-8674
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist