1023234291 NPI number — MS. EVANGELINA GOMEZ CADC

Table of content: MS. EVANGELINA GOMEZ CADC (NPI 1023234291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023234291 NPI number — MS. EVANGELINA GOMEZ CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMEZ
Provider First Name:
EVANGELINA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOMEZ
Provider Other First Name:
EVA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CADC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1023234291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 EMELINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95060-1976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-454-4170
Provider Business Mailing Address Fax Number:
831-454-4663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 EMELINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95060-1976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-454-4170
Provider Business Practice Location Address Fax Number:
831-454-4663
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CADC G0605261426 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ91892Z . This is a "SANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70042F . This is a "SANTA CRUZ COUNTY CALIFORNIA MEDI-CAL GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70044F . This is a "SANTA CRUZ COUNTY CALIFORNIA MEDI-CAL GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G0605261426 . This is a "CADC REGISTRATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ91891Z . This is a "SANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ92069Z . This is a "SANTA CRUZ COUNTY CALIFORNIA MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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