Provider Demographics
NPI:1699414391
Name:POMBOZA, BRYAN (NONE)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:POMBOZA
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92871-0253
Mailing Address - Country:US
Mailing Address - Phone:347-542-1511
Mailing Address - Fax:
Practice Address - Street 1:680 LANGSDORF DR STE 200
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3702
Practice Address - Country:US
Practice Address - Phone:714-871-9264
Practice Address - Fax:714-871-5032
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148644106H00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist