Individual
GOMER GO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
203 COVINGTON WAY, VIENNA, WV 26105-8096
(740) 371-0610
Mailing address
2600 COMPASS RD, GLENVIEW, IL 60026-8001
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
F903373
DRIVER'S LICENSE
WV
Enumeration date
05/22/2019
Last updated
05/22/2019
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