Provider Demographics
NPI:1417964347
Name:DOMINGO, EDEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38053 BUXTON COMMON
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536
Mailing Address - Country:US
Mailing Address - Phone:510-745-7632
Mailing Address - Fax:510-713-6682
Practice Address - Street 1:39500 LIBERTY STREET
Practice Address - Street 2:TRI CITY HEALTH CENTER
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-770-8133
Practice Address - Fax:510-770-8140
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504673163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse