Basic Information
| Provider Information | |||||||||
| NPI: | 1619114899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POOYANDEH CHIROPRACTIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 502 W HOLT AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917683604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096205699 | ||||||||
| FaxNumber: | 9096205799 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 W HOLT AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917683604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096205699 | ||||||||
| FaxNumber: | 9096205799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2009 | ||||||||
| LastUpdateDate: | 01/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | POOYANDEH | ||||||||
| AuthorizedOfficialFirstName: | RASOUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9096205699 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 27512 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.