MEDICARE: KELLY GOMEZ MS, RDN, CD, LD

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	133V00000X	Registered Dietitian	12415870-4901	UT

General Provider Information

NPI Number	:	1114676558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY GOMEZ MS, RDN, CD, LD

Provider Business Mailing Address
First Line	:	5263 S COMMERCE DR STE 201
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5263 S COMMERCE DR STE 201
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5306
Country	:	US
Telephone Number	:	801-882-7802
Fax Number	:

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

Provider Enumeration Date	:	03/22/2022
Last Update Date	:	03/22/2022

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