Healthcare Provider Details

I. General information

NPI: 1861524688
Provider Name (Legal Business Name): BETH S GOMEZ P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6865 ALTON PKWY SUITE 110
IRVINE CA
92618-3735
US

IV. Provider business mailing address

PO BOX 8125
FOUNTAIN VALLEY CA
92728-8125
US

V. Phone/Fax

Practice location:
  • Phone: 949-727-1858
  • Fax: 949-727-1868
Mailing address:
  • Phone: 949-727-1858
  • Fax: 949-727-1868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberPT26517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: