Provider Demographics
NPI:1366033391
Name:GOMEZ, JOSE JESUS (ATC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JESUS
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WEST VEDUGO AVE
Mailing Address - Street 2:UNIT M
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502
Mailing Address - Country:US
Mailing Address - Phone:818-559-1357
Mailing Address - Fax:
Practice Address - Street 1:1500 N VERDUGO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-2809
Practice Address - Country:US
Practice Address - Phone:818-240-1000
Practice Address - Fax:818-291-6621
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator