Healthcare Provider Details

I. General information

NPI: 1861669459
Provider Name (Legal Business Name): DOMEL BRIONES EVANGELISTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 HEMLOCK WAY
SANTA ANA CA
92707-3609
US

IV. Provider business mailing address

1607 CALLE DEL SOL APARTMENT H
ANAHEIM CA
92802
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-1966
  • Fax:
Mailing address:
  • Phone: 714-563-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 226734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: