Provider Demographics
NPI:1205190709
Name:DOMINGUEZ, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5370 E CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-2100
Mailing Address - Country:US
Mailing Address - Phone:702-994-4358
Mailing Address - Fax:
Practice Address - Street 1:1120 N TOWN CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6301
Practice Address - Country:US
Practice Address - Phone:866-960-7691
Practice Address - Fax:866-960-7692
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant