Healthcare Provider Details

I. General information

NPI: 1356257570
Provider Name (Legal Business Name): GUSTAVO GARCIA GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 ILLINOIS ST STE 101
SAN DIEGO CA
92104-3058
US

IV. Provider business mailing address

3928 ILLINOIS ST STE 101
SAN DIEGO CA
92104-3058
US

V. Phone/Fax

Practice location:
  • Phone: 619-763-1140
  • Fax:
Mailing address:
  • Phone: 619-763-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1454670826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: