Healthcare Provider Details

I. General information

NPI: 1457059396
Provider Name (Legal Business Name): DOMAINE ORILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9310 STARCREST DR
SAN ANTONIO TX
78217-4138
US

IV. Provider business mailing address

14080 NACOGDOCHES RD
SAN ANTONIO TX
78247-1944
US

V. Phone/Fax

Practice location:
  • Phone: 210-727-3399
  • Fax:
Mailing address:
  • Phone: 210-727-3399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number37775810
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: