Provider Demographics
NPI:1013135656
Name:POOYANDEH, RASOUL (DC)
Entity type:Individual
Prefix:MR
First Name:RASOUL
Middle Name:
Last Name:POOYANDEH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:RASOUL
Other - Middle Name:
Other - Last Name:POOYANDEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CHIROPRACTOR
Mailing Address - Street 1:502 W HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3604
Mailing Address - Country:US
Mailing Address - Phone:909-620-5699
Mailing Address - Fax:
Practice Address - Street 1:502 W. HOLT AVE.
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768
Practice Address - Country:US
Practice Address - Phone:909-620-5699
Practice Address - Fax:909-620-5799
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27512111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0275120Medicaid
CADC0275120OtherBLUE SHIELD OF CALIFORNIA
CADC0275120Medicaid