Provider Demographics
NPI:1104984798
Name:SUBADYA, KORNELIUS TJANDRA (DC)
Entity type:Individual
Prefix:DR
First Name:KORNELIUS
Middle Name:TJANDRA
Last Name:SUBADYA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4709
Mailing Address - Country:US
Mailing Address - Phone:626-576-1234
Mailing Address - Fax:
Practice Address - Street 1:1014 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4709
Practice Address - Country:US
Practice Address - Phone:626-576-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor