Healthcare Provider Details

I. General information

NPI: 1841819661
Provider Name (Legal Business Name): CHRISTINE DOMINGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 04/11/2020
Certification Date: 04/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 CENTRAL AVE
WAILUKU HI
96793-1723
US

IV. Provider business mailing address

2072 KAMAILE ST
WAILUKU HI
96793-5457
US

V. Phone/Fax

Practice location:
  • Phone: 808-285-7803
  • Fax:
Mailing address:
  • Phone: 808-285-7803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberEL-45
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: