Healthcare Provider Details

I. General information

NPI: 1962145029
Provider Name (Legal Business Name): GNOSIS GERIATRIC WELLCARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/16/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 GARDEN GROVE BLVD STE 304
GARDEN GROVE CA
92843-1903
US

IV. Provider business mailing address

2617 E CHAPMAN AVE
ORANGE CA
92869-3226
US

V. Phone/Fax

Practice location:
  • Phone: 714-353-5333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GERARDO CANCHOLA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 714-353-5333