Healthcare Provider Details

I. General information

NPI: 1205326055
Provider Name (Legal Business Name): XIOMARA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 NW 72ND AVE STE 720
MIAMI FL
33126-1932
US

IV. Provider business mailing address

6850 W 14TH CT APT 2B
HIALEAH FL
33014-4549
US

V. Phone/Fax

Practice location:
  • Phone: 786-409-3423
  • Fax: 786-409-3427
Mailing address:
  • Phone: 786-409-3423
  • Fax: 786-409-3427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number2017016005
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number0-02-0571
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: