Healthcare Provider Details

I. General information

NPI: 1215854112
Provider Name (Legal Business Name): BRENDA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 S CITRUS AVE
AZUSA CA
91702-4733
US

IV. Provider business mailing address

929 W D ST
ONTARIO CA
91762-3025
US

V. Phone/Fax

Practice location:
  • Phone: 626-858-9500
  • Fax:
Mailing address:
  • Phone: 909-268-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number746955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: