Healthcare Provider Details

I. General information

NPI: 1265359749
Provider Name (Legal Business Name): GORGESNAVARRO LOSLEONESPUEBLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11723 FAIR OAKS BLVD
FAIR OAKS CA
95628-2816
US

IV. Provider business mailing address

580 HOWARD AVE
SOMERSET NJ
08873-1113
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: --
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA8565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: