Healthcare Provider Details

I. General information

NPI: 1447713300
Provider Name (Legal Business Name): GERSHOM ISRAEL CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

555 W ALVARADO ST
POMONA CA
91768-2422
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-6061
  • Fax:
Mailing address:
  • Phone: 909-524-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: