Provider Demographics
NPI:1932842069
Name:GOMEZ, SUIRA (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUIRA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:SUIRA
Other - Middle Name:
Other - Last Name:MURILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:9632 GROVE HILL LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-1556
Mailing Address - Country:US
Mailing Address - Phone:954-512-0826
Mailing Address - Fax:
Practice Address - Street 1:9785 CROSSHILL BLVD # 108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-5823
Practice Address - Country:US
Practice Address - Phone:904-772-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-17
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL48277225700000X
FLMA48277172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA48277OtherMA 48277