MEDICARE: GOMEZ PERSONAL INJURY CLINIC INC

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	261Q00000X	Clinic/Center	HCC6681	FL

General Provider Information

NPI Number	:	1780731463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOMEZ PERSONAL INJURY CLINIC INC

Provider Business Mailing Address
First Line	:	4602 N ARMENIA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-2703
Country	:	US
Telephone Number	:	813-876-1690
Fax Number	:	813-876-1653

Provider Business Practice Location Address
First Line	:	4602 N ARMENIA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-2703
Country	:	US
Telephone Number	:	813-876-1690
Fax Number	:	813-876-1690

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. EULOGIO DAVID GOMEZ I
Credential	:
Telephone Number	:	813-876-1690

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	05/09/2008

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