Healthcare Provider Details

I. General information

NPI: 1881344281
Provider Name (Legal Business Name): DOMINGUEZ DEVELOPMENT GROUP INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 S LA GRANGE RD STE 9
LA GRANGE IL
60525-6318
US

IV. Provider business mailing address

72 S LA GRANGE RD STE 9
LA GRANGE IL
60525-6318
US

V. Phone/Fax

Practice location:
  • Phone: 708-832-4042
  • Fax: 708-854-6038
Mailing address:
  • Phone: 708-832-4042
  • Fax: 708-854-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. JACQUELINE HERMENCIA DOMINGUEZ
Title or Position: CO-OWNER/ADMINISTRATOR
Credential: RN, BSN
Phone: 708-244-9225