Provider Demographics
NPI:1275891244
Name:GOMEZ, MARY JO FLORES
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:FLORES
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 1:610 N CENTRAL AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1418
Mailing Address - Country:US
Mailing Address - Phone:818-551-0026
Mailing Address - Fax:818-551-0027
Practice Address - Street 1:610 N CENTRAL AVE STE 106
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1418
Practice Address - Country:US
Practice Address - Phone:818-551-0026
Practice Address - Fax:818-551-0027
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator