Basic Information
| Provider Information | |||||||||
| NPI: | 1760823322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | ROCIO | ||||||||
| MiddleName: | |||||||||
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| Credential: | LVN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMEZ | ||||||||
| OtherFirstName: | ROSIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10986 WAGON TRAIN RD | ||||||||
| Address2: | |||||||||
| City: | PHELAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923718169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238280494 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 681 S PARKER ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147440900 | ||||||||
| FaxNumber: | 8775935583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 270659 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.