Provider Demographics
NPI:1952644932
Name:R B GONZALES MEDICAL AND BARIATRIC CENTER INC
Entity Type:Organization
Organization Name:R B GONZALES MEDICAL AND BARIATRIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-235-4000
Mailing Address - Street 1:1361 FORT HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-1203
Mailing Address - Country:US
Mailing Address - Phone:812-235-4000
Mailing Address - Fax:812-235-4004
Practice Address - Street 1:1361 FORT HARRISON RD
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1203
Practice Address - Country:US
Practice Address - Phone:812-235-4000
Practice Address - Fax:812-235-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND93419Medicare UPIN
607750Medicare PIN