Provider Demographics
NPI:1578964078
Name:AMANDA GOMEZ
Entity Type:Organization
Organization Name:AMANDA GOMEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-205-6628
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:TX
Mailing Address - Zip Code:75925-0206
Mailing Address - Country:US
Mailing Address - Phone:936-205-6628
Mailing Address - Fax:
Practice Address - Street 1:113 TYLER AVE
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:TX
Practice Address - Zip Code:75925-3306
Practice Address - Country:US
Practice Address - Phone:936-205-6628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001004322Medicaid