Healthcare Provider Details

I. General information

NPI: 1245966621
Provider Name (Legal Business Name): JOSHUA DOMINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12912 BROOKHURST ST STE 480
GARDEN GROVE CA
92840-4867
US

IV. Provider business mailing address

12912 BROOKHURST ST STE 480
GARDEN GROVE CA
92840-4867
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-6286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: