Healthcare Provider Details

I. General information

NPI: 1073281754
Provider Name (Legal Business Name): LEO ERNIE MANANGAN DOMINGO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 ATLANTIC AVE
LONG BEACH CA
90805-4710
US

IV. Provider business mailing address

929 E 3RD ST
SANTA ANA CA
92701-4906
US

V. Phone/Fax

Practice location:
  • Phone: 562-580-0910
  • Fax:
Mailing address:
  • Phone: 619-888-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95018365
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number827301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: