1851983662 NPI number — JEREMY V GOMER MD PHD PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1851983662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851983662 NPI number — JEREMY V GOMER MD PHD PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEREMY V GOMER MD PHD PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VIRTUE PRIMARY CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851983662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1881 COMMERCENTER E STE 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92408-3443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-533-0786
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27403 YNEZ RD STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92591-4619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-750-7888
Provider Business Practice Location Address Fax Number:
951-750-7899
Provider Enumeration Date:
02/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GOMER
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
VETHAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-750-7888

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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