Healthcare Provider Details

I. General information

NPI: 1942268784
Provider Name (Legal Business Name): GERARD GUMBOC P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 E LOS ANGELES AVE
SIMI VALLEY CA
93065-3937
US

IV. Provider business mailing address

501 S GLENWOOD PL
BURBANK CA
91506-2516
US

V. Phone/Fax

Practice location:
  • Phone: 805-526-8360
  • Fax: 805-526-1438
Mailing address:
  • Phone: 951-676-2675
  • Fax: 951-676-2645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: