Healthcare Provider Details

I. General information

NPI: 1811859663
Provider Name (Legal Business Name): ROSAURA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E. ROSSER AVE STE 113
BISMARCK ND
58501-4058
US

IV. Provider business mailing address

415 E. ROSSER AVE STE 113
BISMARCK ND
58501-4058
US

V. Phone/Fax

Practice location:
  • Phone: 701-222-6670
  • Fax:
Mailing address:
  • Phone: 701-222-6670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: