Provider Demographics
NPI:1396320867
Name:HOMBO, THOMAS (ATC, PTA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:HOMBO
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 N WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1521
Mailing Address - Country:US
Mailing Address - Phone:909-599-7002
Mailing Address - Fax:
Practice Address - Street 1:1043 N WALNUT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1521
Practice Address - Country:US
Practice Address - Phone:909-599-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51094225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty