Basic Information
| Provider Information | |||||||||
| NPI: | 1417964347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGO | ||||||||
| FirstName: | EDEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38053 BUXTON COMMON | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107457632 | ||||||||
| FaxNumber: | 5107136682 | ||||||||
| Practice Location | |||||||||
| Address1: | 39500 LIBERTY STREET | ||||||||
| Address2: | TRI CITY HEALTH CENTER | ||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107708133 | ||||||||
| FaxNumber: | 5107708140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 504673 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.