Provider Demographics
NPI:1801294673
Name:GONZALES, ALFRED RANDALL (ATC)
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:RANDALL
Last Name:GONZALES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15755 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-6313
Mailing Address - Country:US
Mailing Address - Phone:225-753-1200
Mailing Address - Fax:225-751-9269
Practice Address - Street 1:15755 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-6313
Practice Address - Country:US
Practice Address - Phone:225-753-1200
Practice Address - Fax:225-751-9269
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATHJ000722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer