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General NPI Number Information
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NPI Number | 1578950333
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Entity Type | Organization
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Legal Business Name | SPORTS CONCUSSION TREATMENT CENTER OF TEXAS
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Dates
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Enumeration Date | 04/20/2015
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Last Update Date | 04/20/2015
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Provider Practice Location Address
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Address Line | 2940 FM 407 SUITE 302
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City | HIGHLAND VILLAGE
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State | TX
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Zip | 75077-7045
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Country | US
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Telephone | 972-316-9011
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Fax |
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Provider Business Mailing Address
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Address Line | 2940 FM 407 SUITE 302
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City | HIGHLAND VILLAGE
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State | TX
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Zip | 75077-7045
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Country | US
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Telephone | 972-316-9011
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. JOHN GUSTAVO GOMEZ
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Credential | M.D.
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Telephone | 940-231-1129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | L1055
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License Number State | TX
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