MEDICARE: AMANDA GOMEZ

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	311ZA0620X	Adult Care Home Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578964078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMANDA GOMEZ

Provider Business Mailing Address
First Line	:	PO BOX 206
Second Line	:
City	:	ALTO
State	:	TX
Zip	:	75925-0206
Country	:	US
Telephone Number	:	936-205-6628
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 TYLER AVE
Second Line	:
City	:	ALTO
State	:	TX
Zip	:	75925-3306
Country	:	US
Telephone Number	:	936-205-6628
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMANDA GOMEZ
Credential	:
Telephone Number	:	936-205-6628

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	09/16/2014

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Directions to “AMANDA GOMEZ ” Practice Location

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