Provider Demographics
NPI:1578503587
Name:GAMBOA, RODIMIRO DESI (DC)
Entity Type:Individual
Prefix:DR
First Name:RODIMIRO
Middle Name:DESI
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 ROOSEVELT ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1688
Mailing Address - Country:US
Mailing Address - Phone:760-729-0252
Mailing Address - Fax:760-730-9911
Practice Address - Street 1:2808 ROOSEVELT ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1688
Practice Address - Country:US
Practice Address - Phone:760-729-0252
Practice Address - Fax:760-730-9911
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20468OtherSTATE LICENSE
CAU11847Medicare UPIN