Provider Demographics
NPI:1619047602
Name:GO, SIMON REYES (DC)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:REYES
Last Name:GO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14623 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1581
Mailing Address - Country:US
Mailing Address - Phone:310-675-8803
Mailing Address - Fax:310-370-7380
Practice Address - Street 1:14623 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1581
Practice Address - Country:US
Practice Address - Phone:310-675-8803
Practice Address - Fax:310-370-7380
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20602111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC20602AMedicare ID - Type UnspecifiedPROVIDER NUMBER