Healthcare Provider Details

I. General information

NPI: 1396521241
Provider Name (Legal Business Name): RITA GENOVEVA DOMINGUEZ ROMAN CHW2
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6285 ANGORA PEAK LN
LAS VEGAS NV
89115-1662
US

IV. Provider business mailing address

6285 ANGORA PEAK LN
LAS VEGAS NV
89115-1662
US

V. Phone/Fax

Practice location:
  • Phone: 954-860-3216
  • Fax:
Mailing address:
  • Phone: 954-860-3216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number207Q00000X
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: