Provider Demographics
NPI:1497173157
Name:BOEK-DOMINGUEZ, STACEY (MS, RD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BOEK-DOMINGUEZ
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 SISTER MARY COLUMBA DR
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-4327
Mailing Address - Country:US
Mailing Address - Phone:530-529-8113
Mailing Address - Fax:530-242-2509
Practice Address - Street 1:2550 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-529-8113
Practice Address - Fax:530-242-2509
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1019706133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered