Provider Demographics
NPI:1881968030
Name:GONZALEZ, KALESHA GONZALEZ (IDMT)
Entity type:Individual
Prefix:MRS
First Name:KALESHA
Middle Name:GONZALEZ
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21118 AMIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-707-6453
Mailing Address - Fax:
Practice Address - Street 1:21118 AMIE AVENUE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503
Practice Address - Country:US
Practice Address - Phone:310-707-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians