Basic Information
| Provider Information | |||||||||
| NPI: | 1891334504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MIGUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W HUNTINGTON DR APT 1I | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 918011234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263426683 | ||||||||
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| Practice Location | |||||||||
| Address1: | 36 S KINNELOA AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268443033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2019 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 281775 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.