Provider Demographics
NPI:1275180960
Name:GOMEZ, ROSA L
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:L
Last Name:GOMEZ
Suffix:
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 1:400 W BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:SALUDA
Mailing Address - State:SC
Mailing Address - Zip Code:29138-1312
Mailing Address - Country:US
Mailing Address - Phone:864-445-2564
Mailing Address - Fax:864-445-8833
Practice Address - Street 1:400 W BUTLER AVE
Practice Address - Street 2:
Practice Address - City:SALUDA
Practice Address - State:SC
Practice Address - Zip Code:29138-1312
Practice Address - Country:US
Practice Address - Phone:864-445-2564
Practice Address - Fax:864-445-8833
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC242483163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool