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NPI Code Detail

MEDICARE: WALTER ALEXANDER DOMINGUEZ JR.

MEDICARE: WALTER ALEXANDER DOMINGUEZ JR.
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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1578452033
Entity Type Code : Individual
Provider Name (Legal Business Name) : WALTER ALEXANDER DOMINGUEZ JR.
Provider Business Mailing Address
First Line : 2139 S CLOVERDALE AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90016-1211
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11287 WASHINGTON BLVD
Second Line :
City : CULVER CITY
State : CA
Zip : 90230-4615
Country : US
Telephone Number : 323-240-5560
Fax Number : 323-372-3972
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2025
Last Update Date : 06/30/2025

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