Healthcare Provider Details

I. General information

NPI: 1912341421
Provider Name (Legal Business Name): DOMINIQUE BUENAVIDES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N WINDING BROOK RD
FLAGSTAFF AZ
86001-0972
US

IV. Provider business mailing address

800 W FOREST MEADOWS ST APT 121
FLAGSTAFF AZ
86001-2903
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-7106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5102
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: