Provider Demographics
NPI:1932558491
Name:POMARES, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:POMARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 COMMERCE BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2181
Mailing Address - Country:US
Mailing Address - Phone:707-297-9668
Mailing Address - Fax:
Practice Address - Street 1:6040 COMMERCE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928
Practice Address - Country:US
Practice Address - Phone:415-827-9747
Practice Address - Fax:707-387-1915
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16613171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932558491Medicaid