Provider Demographics
NPI:1386201507
Name:GO, GOMER
Entity Type:Individual
Prefix:
First Name:GOMER
Middle Name:
Last Name:GO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 COMPASS RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 COVINGTON WAY
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-8096
Practice Address - Country:US
Practice Address - Phone:740-371-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVF903373OtherDRIVER'S LICENSE