Healthcare Provider Details

I. General information

NPI: 1710643457
Provider Name (Legal Business Name): JONATHAN GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 MARKET ST
RIVERSIDE CA
92501-1720
US

IV. Provider business mailing address

1950 MARKET ST
RIVERSIDE CA
92501-1720
US

V. Phone/Fax

Practice location:
  • Phone: 951-530-5900
  • Fax: 951-530-5900
Mailing address:
  • Phone: 951-530-5900
  • Fax: 951-530-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberACSW130911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: