Healthcare Provider Details

I. General information

NPI: 1699414391
Provider Name (Legal Business Name): BRYAN POMBOZA NONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 LANGSDORF DR STE 200
FULLERTON CA
92831-3702
US

IV. Provider business mailing address

PO BOX 253
PLACENTIA CA
92871-0253
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-9264
  • Fax: 714-871-5032
Mailing address:
  • Phone: 347-542-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number148644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: