Healthcare Provider Details

I. General information

NPI: 1720633050
Provider Name (Legal Business Name): VIRCELITO A. DOMENDEN I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 11/08/2025
Certification Date: 11/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 POTRERO AVE
SAN FRANCISCO CA
94110-2869
US

IV. Provider business mailing address

30685 UNION CITY BLVD
UNION CITY CA
94587-2546
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-2855
  • Fax:
Mailing address:
  • Phone: 510-502-8589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: