Provider Demographics
NPI:1942320569
Name:GOMEZ, RANDY (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CADET LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4928
Mailing Address - Country:US
Mailing Address - Phone:337-261-1658
Mailing Address - Fax:
Practice Address - Street 1:100 WILLIAM O STUTES ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7211
Practice Address - Country:US
Practice Address - Phone:337-406-0712
Practice Address - Fax:337-406-0715
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04488F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist