Healthcare Provider Details

I. General information

NPI: 1902180466
Provider Name (Legal Business Name): M. GOMEZ INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 N LINCOLN AVE LOWER LEVEL
CHICAGO IL
60614-7600
US

IV. Provider business mailing address

2266 N LINCOLN AVE LOWER LEVEL
CHICAGO IL
60614-7600
US

V. Phone/Fax

Practice location:
  • Phone: 773-883-3953
  • Fax: 773-883-3649
Mailing address:
  • Phone: 773-883-3953
  • Fax: 773-883-3649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.008312
License Number StateIL

VIII. Authorized Official

Name: MELJUN GOMEZ
Title or Position: PRESIDENT
Credential: NP-C
Phone: 773-744-2935