Healthcare Provider Details

I. General information

NPI: 1508980145
Provider Name (Legal Business Name): OLMA DOMINGUEZ 1184
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1614
US

IV. Provider business mailing address

1111 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1614
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5501
  • Fax: 505-255-9971
Mailing address:
  • Phone: 505-255-5501
  • Fax: 505-255-9971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number1184
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: