Healthcare Provider Details

I. General information

NPI: 1205571452
Provider Name (Legal Business Name): RAFAEL DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date: 03/25/2026
Reactivation Date: 04/10/2026

III. Provider practice location address

1317 OAKDALE RD
MODESTO CA
95355-3361
US

IV. Provider business mailing address

2080 N TUSTIN AVE STE B
SANTA ANA CA
92705-7875
US

V. Phone/Fax

Practice location:
  • Phone: 855-581-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: