Provider Demographics
NPI:1043606882
Name:GOMEZ, KRYSTAL (ATC)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14802 GARDENHILL DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-3017
Mailing Address - Country:US
Mailing Address - Phone:562-355-4829
Mailing Address - Fax:
Practice Address - Street 1:2432 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40209-1805
Practice Address - Country:US
Practice Address - Phone:502-852-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT11632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer