Basic Information
| Provider Information | |||||||||
| NPI: | 1851669964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 993 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917662124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269996838 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1126 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269671667 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2011 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.