Provider Demographics
NPI:1487053864
Name:LOYAL SOURCE GOVERNMENT SERVICES
Entity type:Organization
Organization Name:LOYAL SOURCE GOVERNMENT SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MSN, FNP-C
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBALA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:619-301-9112
Mailing Address - Street 1:900 RIGLEY ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-7003
Mailing Address - Country:US
Mailing Address - Phone:619-301-9112
Mailing Address - Fax:
Practice Address - Street 1:3680 AVALON PARK EAST BLVD STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9374
Practice Address - Country:US
Practice Address - Phone:407-381-7734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000947302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95000947Medicaid
CA95000947Medicaid
CA95000947Medicare Oscar/Certification
CA95000947Medicare PIN