MEDICARE: ANTOINETTE DOMINGO PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501011514	MI

General Provider Information

NPI Number	:	1659783553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTOINETTE DOMINGO PT

Provider Business Mailing Address
First Line	:	5500 CAMPANILE DR
Second Line	:	ENS
City	:	SAN DIEGO
State	:	CA
Zip	:	92182-7251
Country	:	US
Telephone Number	:	619-594-3289
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 CAMPANILE DR
Second Line	:	ENS
City	:	SAN DIEGO
State	:	CA
Zip	:	92182-7251
Country	:	US
Telephone Number	:	619-594-3289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	05/27/2014

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