Healthcare Provider Details

I. General information

NPI: 1245084458
Provider Name (Legal Business Name): MARK RYAN VENTURA DOMINGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33608 ORTEGA HWY SAN JUAN CAPISTRANO
SAN JUAN CAPISTRANO CA
92675
US

IV. Provider business mailing address

70 SKLAR ST APT 603
LADERA RANCH CA
92694-0766
US

V. Phone/Fax

Practice location:
  • Phone: 800-642-4657
  • Fax:
Mailing address:
  • Phone: 949-615-8407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberMTA-02245121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: