Provider Demographics
NPI:1164786349
Name:BOUROUMAND, KEYHANEH DANAEE (DC)
Entity Type:Individual
Prefix:
First Name:KEYHANEH
Middle Name:DANAEE
Last Name:BOUROUMAND
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9374
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-8374
Mailing Address - Country:US
Mailing Address - Phone:213-272-7028
Mailing Address - Fax:909-743-4022
Practice Address - Street 1:7762 EDISON AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3638
Practice Address - Country:US
Practice Address - Phone:909-743-4022
Practice Address - Fax:909-743-4022
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor