MEDICARE: RITA GENOVEVA DOMINGUEZ ROMAN CHW2

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker
2	101YP1600X	Pastoral Counselor		NV
3	172V00000X	Community Health Worker	207Q00000X	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	193200000X	OTHER	NV	MULTI SPECIALTY-GROUP

General Provider Information

NPI Number	:	1396521241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RITA GENOVEVA DOMINGUEZ ROMAN CHW2

Provider Business Mailing Address
First Line	:	6285 ANGORA PEAK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-1662
Country	:	US
Telephone Number	:	954-860-3216
Fax Number	:

Provider Business Practice Location Address
First Line	:	6285 ANGORA PEAK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-1662
Country	:	US
Telephone Number	:	954-860-3216
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2023
Last Update Date	:	12/05/2025

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