MEDICARE: KADESH GAMALL GAYLE CPO

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	222Z00000X	Orthotist	CPO04275	CA

General Provider Information

NPI Number	:	1043876162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KADESH GAMALL GAYLE CPO

Provider Business Mailing Address
First Line	:	20595 SPRING ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-0128
Country	:	US
Telephone Number	:	951-452-3951
Fax Number	:

Provider Business Practice Location Address
First Line	:	20595 SPRING ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-0128
Country	:	US
Telephone Number	:	951-452-3951
Fax Number	:

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

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	05/14/2019

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