Healthcare Provider Details

I. General information

NPI: 1407466774
Provider Name (Legal Business Name): CARLOS MANUEL GOMEZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 NW 150TH AVE STE 120
PEMBROKE PINES FL
33028-2888
US

IV. Provider business mailing address

4740 N STATE ROAD 7
LAUDERDALE LAKES FL
33319-5839
US

V. Phone/Fax

Practice location:
  • Phone: 954-719-6280
  • Fax:
Mailing address:
  • Phone: 954-486-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPRN11007700
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11007700
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11007700
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11007700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: