Provider Demographics
NPI:1376200311
Name:GOMEZ VARGAS, BERENISE GOMEZ VARGAS
Entity Type:Individual
Prefix:
First Name:BERENISE
Middle Name:GOMEZ VARGAS
Last Name:GOMEZ VARGAS
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 1:3200 NORTHWOOD DR APT 311
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4503
Mailing Address - Country:US
Mailing Address - Phone:209-761-4185
Mailing Address - Fax:
Practice Address - Street 1:2740 GRANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2265
Practice Address - Country:US
Practice Address - Phone:925-674-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered