Provider Demographics
NPI:1477264695
Name:GOMEZ CLINIC CORP
Entity Type:Organization
Organization Name:GOMEZ CLINIC CORP
Other - Org Name:GOMEZ CLINIC CORP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:305-300-5551
Mailing Address - Street 1:6583 SW 39TH TER STE B
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4821
Mailing Address - Country:US
Mailing Address - Phone:305-300-5551
Mailing Address - Fax:
Practice Address - Street 1:6583 SW 39TH TER STE B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4821
Practice Address - Country:US
Practice Address - Phone:786-747-4949
Practice Address - Fax:786-756-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-08
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty