Healthcare Provider Details

I. General information

NPI: 1669757811
Provider Name (Legal Business Name): STEVEN CHARLES DOMAGALA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3090 LAKESIDE DR
WILLOW RIVER MN
55795-3327
US

IV. Provider business mailing address

3090 LAKESIDE DR
WILLOW RIVER MN
55795-3327
US

V. Phone/Fax

Practice location:
  • Phone: 507-304-1689
  • Fax:
Mailing address:
  • Phone: 507-304-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR149110-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: