Basic Information
| Provider Information | |||||||||
| NPI: | 1396075461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POMARES | ||||||||
| FirstName: | BURNSHELL | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | BURNSHELL | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LVN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 769 W BLAINE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 769 W BLAINE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513854705 | ||||||||
| FaxNumber: | 9513584719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 244130 | CA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.