MEDICARE: GREGORY GOMEZ II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1659771467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY GOMEZ II

Provider Business Mailing Address
First Line	:	3021 S HACIENDA BLVD
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-5331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3021 S HACIENDA BLVD
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-5331
Country	:	US
Telephone Number	:	626-290-4052
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2014
Last Update Date	:	10/14/2014

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