Provider Demographics
NPI:1578811535
Name:POUTEYMOOR, KOMBIZ (DC)
Entity Type:Individual
Prefix:DR
First Name:KOMBIZ
Middle Name:
Last Name:POUTEYMOOR
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 1:5278 RANCH GATE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-1217
Mailing Address - Country:US
Mailing Address - Phone:909-559-5061
Mailing Address - Fax:
Practice Address - Street 1:789 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:310-519-0330
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-24
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32368111N00000X
CA15461171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist