Healthcare Provider Details

I. General information

NPI: 1588685226
Provider Name (Legal Business Name): FRENALYN BACATE DOMINGO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22040 VAN BUREN ST
GRAND TERRACE CA
92313
US

IV. Provider business mailing address

25612 BARTON RD 335
LOMA LINDA CA
92354-3110
US

V. Phone/Fax

Practice location:
  • Phone: 909-677-7850
  • Fax: 909-494-7542
Mailing address:
  • Phone: 909-709-7941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP 13242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: