1255517546 NPI number — CRYSTAL NERENCE GOMEZ CUNANAN RPT

Table of content: CRYSTAL NERENCE GOMEZ CUNANAN RPT (NPI 1255517546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255517546 NPI number — CRYSTAL NERENCE GOMEZ CUNANAN RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNANAN
Provider First Name:
CRYSTAL NERENCE
Provider Middle Name:
GOMEZ
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
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:
CRYSTAL NERENCE
Provider Other Middle Name:
DE GUIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255517546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2470 MARTIN ANTHONY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95377-6628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-799-7760
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2586 BUTHMANN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95376-2165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-832-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2008

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: 225100000X , with the licence number:  PT32788 , 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)





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