Healthcare Provider Details

I. General information

NPI: 1639932643
Provider Name (Legal Business Name): GEROME COSME VIRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 STUDEBAKER RD
NORWALK CA
90650-2500
US

IV. Provider business mailing address

13100 STUDEBAKER RD
NORWALK CA
90650-2500
US

V. Phone/Fax

Practice location:
  • Phone: 855-464-2234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95289671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: