Provider Demographics
NPI:1245516913
Name:GOMEZ, LARISSA R
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:R
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 EMBER ST
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-5704
Mailing Address - Country:US
Mailing Address - Phone:775-727-0101
Mailing Address - Fax:775-727-0606
Practice Address - Street 1:280 EMBER ST
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5704
Practice Address - Country:US
Practice Address - Phone:775-727-0101
Practice Address - Fax:775-727-0606
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner