Provider Demographics
NPI:1639402068
Name:REQUINA, DOMINIC BARRO
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:BARRO
Last Name:REQUINA
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 1:3330 ALAMOS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-5001
Mailing Address - Country:US
Mailing Address - Phone:718-501-2126
Mailing Address - Fax:559-348-1289
Practice Address - Street 1:3330 ALAMOS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-5001
Practice Address - Country:US
Practice Address - Phone:718-501-2126
Practice Address - Fax:559-348-1289
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist