Provider Demographics
NPI:1982725198
Name:SAM KHUMOORO CHIROPRACTIC PROFESSINAL CORPORATION
Entity Type:Organization
Organization Name:SAM KHUMOORO CHIROPRACTIC PROFESSINAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:PUTRES
Authorized Official - Last Name:KHUMOORO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:1909-838-0134
Mailing Address - Street 1:23080 ALESSANDRO BLVD
Mailing Address - Street 2:STE. 204
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9673
Mailing Address - Country:US
Mailing Address - Phone:951-571-4090
Mailing Address - Fax:951-571-4091
Practice Address - Street 1:23080 ALESSANDRO BLVD
Practice Address - Street 2:STE. 204
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9673
Practice Address - Country:US
Practice Address - Phone:951-571-4090
Practice Address - Fax:951-571-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25727111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty