Basic Information
| Provider Information | |||||||||
| NPI: | 1629477591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | EMILINE | ||||||||
| MiddleName: | LANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960800400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305275631 | ||||||||
| FaxNumber: | 5305270232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 WALNUT ST STE A | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960803611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305275631 | ||||||||
| FaxNumber: | 5305270232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2014 | ||||||||
| LastUpdateDate: | 08/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.