Provider Demographics
NPI:1396381992
Name:VILLEGAS GOMEZ, JUAN CARLOS SIMON (ATC)
Entity Type:Individual
Prefix:
First Name:JUAN CARLOS
Middle Name:SIMON
Last Name:VILLEGAS 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 1:414 E MOUNTAIN VIEW RD APT 804
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1279
Mailing Address - Country:US
Mailing Address - Phone:786-252-1598
Mailing Address - Fax:
Practice Address - Street 1:1081 JOHN ROBERT BELL DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-439-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer