Provider Demographics
NPI:1497957344
Name:TANGSERMWONGSE, KOMPAN TOM (DC)
Entity Type:Individual
Prefix:DR
First Name:KOMPAN
Middle Name:TOM
Last Name:TANGSERMWONGSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 W 6TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1133
Mailing Address - Country:US
Mailing Address - Phone:909-381-3492
Mailing Address - Fax:909-381-3469
Practice Address - Street 1:370 W 6TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1133
Practice Address - Country:US
Practice Address - Phone:909-381-3492
Practice Address - Fax:909-381-3469
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-30462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor