=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396104303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING AND RESTORING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 02/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8704 N. BLUFFVIEW DRIVE
-----------------------------------------------------
City | BERRIEN SPRINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-262-4229
-----------------------------------------------------
Fax | 269-329-2290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8704 N BLUFFVIEW DR
-----------------------------------------------------
City | BERRIEN SPRINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49103-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-262-4229
-----------------------------------------------------
Fax | 269-329-2290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSE ELIAS GOMEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 269-635-3322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number | 4301089165
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------