MEDICARE: MRS. JACQUELINE GOMES PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070-008468	IL

General Provider Information

NPI Number	:	1003027244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE GOMES PT

Provider Business Mailing Address
First Line	:	755 N LAKE DR
Second Line	:
City	:	DU QUOIN
State	:	IL
Zip	:	62832-2451
Country	:	US
Telephone Number	:	618-542-3386
Fax Number	:	618-542-3386

Provider Business Practice Location Address
First Line	:	755 N LAKE DR
Second Line	:
City	:	DU QUOIN
State	:	IL
Zip	:	62832-2451
Country	:	US
Telephone Number	:	618-542-3386
Fax Number	:	618-542-3386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2007
Last Update Date	:	03/15/2010

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