Healthcare Provider Details

I. General information

NPI: 1952991911
Provider Name (Legal Business Name): JUAN CARLOS GOMEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 COLLEGE ST
GRAHAM NC
27253-2206
US

IV. Provider business mailing address

6611 EFLAND CEDAR GROVE RD
CEDAR GROVE NC
27231-9761
US

V. Phone/Fax

Practice location:
  • Phone: 336-228-8394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: