Healthcare Provider Details

I. General information

NPI: 1740768498
Provider Name (Legal Business Name): ELIZABETH RUTH DOMINGUEZ LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E FERGUSON ST STE 608
TYLER TX
75702-5756
US

IV. Provider business mailing address

4615 PEAVY SWITCH RD
LUFKIN TX
75904-7396
US

V. Phone/Fax

Practice location:
  • Phone: 903-705-0070
  • Fax: 903-405-3932
Mailing address:
  • Phone: 469-386-9427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number228182
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: