Provider Demographics
NPI:1477232320
Name:GORGONIO, ERNESTO
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:GORGONIO
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 1:12062 W EDINGER AVE SPC 20
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-3820
Mailing Address - Country:US
Mailing Address - Phone:714-862-4395
Mailing Address - Fax:
Practice Address - Street 1:12062 W EDINGER AVE SPC 20
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-3820
Practice Address - Country:US
Practice Address - Phone:714-862-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician