Healthcare Provider Details

I. General information

NPI: 1780123919
Provider Name (Legal Business Name): MR. DOMINGO M. VALDEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E 7TH ST
MADERA CA
93638-3780
US

IV. Provider business mailing address

209 E 7TH ST
MADERA CA
93638-3780
US

V. Phone/Fax

Practice location:
  • Phone: 559-673-3508
  • Fax: 559-661-2818
Mailing address:
  • Phone: 559-673-3508
  • Fax: 559-661-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberV0907021811
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: