MEDICARE: GABRIEL GOVENDO

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1316324387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIEL GOVENDO

Provider Business Mailing Address
First Line	:	PO BOX 7
Second Line	:
City	:	WOODVILLE
State	:	MA
Zip	:	01784-0007
Country	:	US
Telephone Number	:	510-290-4456
Fax Number	:

Provider Business Practice Location Address
First Line	:	1622 GALISTEO ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4747
Country	:	US
Telephone Number	:	510-290-4456
Fax Number	:

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

Provider Enumeration Date	:	04/29/2015
Last Update Date	:	04/29/2015

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Directions to “ GABRIEL GOVENDO ” Practice Location

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