Healthcare Provider Details

I. General information

NPI: 1003000100
Provider Name (Legal Business Name): GERARDO GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

680 S WILTON PL
LOS ANGELES CA
90005-3200
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 213-365-7400
  • Fax: 213-383-1280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: