Provider Demographics
NPI:1962977371
Name:GUMBO, ELISHA
Entity type:Individual
Prefix:MR
First Name:ELISHA
Middle Name:
Last Name:GUMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37657 BRUTUS WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8056
Mailing Address - Country:US
Mailing Address - Phone:909-800-4885
Mailing Address - Fax:
Practice Address - Street 1:37657 BRUTUS WAY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-8056
Practice Address - Country:US
Practice Address - Phone:909-800-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA768627163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse