Provider Demographics
NPI:1679600829
Name:GONZALES, ANTONIO RAY (DC)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:RAY
Last Name:GONZALES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 LAMBERT ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3413
Mailing Address - Country:US
Mailing Address - Phone:269-684-4200
Mailing Address - Fax:
Practice Address - Street 1:920 LAMBERT ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3413
Practice Address - Country:US
Practice Address - Phone:269-684-4200
Practice Address - Fax:269-262-0943
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2011-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001868A111N00000X
MI2301008841111NR0400X, 111NN1001X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200258400Medicaid
IN200258400Medicaid
IN219100Medicare ID - Type Unspecified