Provider Demographics
NPI:1205386455
Name:DOMINION PROVIDER SERVICES, LLC
Entity Type:Organization
Organization Name:DOMINION PROVIDER SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:HINOJOSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-568-3979
Mailing Address - Street 1:1008 E HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-3287
Mailing Address - Country:US
Mailing Address - Phone:956-568-3979
Mailing Address - Fax:956-568-4014
Practice Address - Street 1:1008 E HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-3287
Practice Address - Country:US
Practice Address - Phone:956-568-3979
Practice Address - Fax:956-568-4014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016977253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX016977Medicaid