Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | 833543 | CA |
NPI | 1639566953 |
---|---|
Provider Name | John Gutierrez |
First Address | Riverside, CA 92503 |
Second Address | Riverside, CA 92503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2015 |
Last Update Date | 24/04/2015 |