Healthcare Provider Details

I. General information

NPI: 1871019737
Provider Name (Legal Business Name): CLARIVEL DOMINGUEZ WELLNESS COACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLARIVEL DOMINGUEZ WELLNESS COACH

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13109 CURTIS AND KING RD
NORWALK CA
90650-2152
US

IV. Provider business mailing address

13109 CURTIS AND KING RD
NORWALK CA
90650-2152
US

V. Phone/Fax

Practice location:
  • Phone: 323-896-1344
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283XC2000X
TaxonomyChildren's Rehabilitation Hospital
License Number1170064024
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1501214442
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: