Provider Demographics
NPI:1528418068
Name:POURTEYMOOR ACUPUNCTURE, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:POURTEYMOOR ACUPUNCTURE, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KOMBIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:POURTEYMOOR
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DC
Authorized Official - Phone:310-519-1557
Mailing Address - Street 1:797 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3601
Practice Address - Country:US
Practice Address - Phone:310-519-1557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15461171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty