Basic Information
| Provider Information | |||||||||
| NPI: | 1821551581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GONZALES HEALTHCARE SYSTEMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIEVERS MEDICAL CLINIC - SHINER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306728481 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 WEST 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | SHINER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3612395015 | ||||||||
| FaxNumber: | 8306728481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LACOSTE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8306727581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.