Provider Demographics
NPI:1114436839
Name:GOMEZ, BLANCA MELISA I
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:MELISA
Last Name:GOMEZ
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4612
Mailing Address - Country:US
Mailing Address - Phone:323-933-9022
Mailing Address - Fax:
Practice Address - Street 1:7423 1/4 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045
Practice Address - Country:US
Practice Address - Phone:310-482-1653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty