Healthcare Provider Details

I. General information

NPI: 1740352301
Provider Name (Legal Business Name): MIA DOMINGO CAMCAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23600 TELO AVE SUITE 150
TORRANCE CA
90505-4035
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-325-3084
  • Fax: 310-325-4938
Mailing address:
  • Phone: 310-206-3748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: