Provider Demographics
NPI:1104978675
Name:DOMBO, TAMBURAI (PT)
Entity type:Individual
Prefix:MISS
First Name:TAMBURAI
Middle Name:
Last Name:DOMBO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3385
Mailing Address - Country:US
Mailing Address - Phone:678-985-7190
Mailing Address - Fax:678-985-7158
Practice Address - Street 1:758 OLD NORCROSS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3385
Practice Address - Country:US
Practice Address - Phone:678-985-7190
Practice Address - Fax:678-985-7158
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist