Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 40706 | CA |
NPI | 1073166484 |
---|---|
Provider Name | Stephanie Alina Gomez |
First Address | Colton, CA 92324-9515 |
Second Address | San Bernardino, CA 92408-3268 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2019 |
Last Update Date | 24/07/2019 |