Healthcare Provider Details

I. General information

NPI: 1700966025
Provider Name (Legal Business Name): MARTHA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W 17TH ST
SANTA ANA CA
92706-2316
US

IV. Provider business mailing address

PO BOX 6099
SANTA ANA CA
92706-0099
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-8173
  • Fax: 714-834-8051
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: