Provider Demographics
NPI:1871836957
Name:DOMINGUEZ, LYNDEN
Entity Type:Individual
Prefix:
First Name:LYNDEN
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 ANO LN
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-4202
Mailing Address - Country:US
Mailing Address - Phone:808-347-3625
Mailing Address - Fax:
Practice Address - Street 1:2001 ANO LN
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4202
Practice Address - Country:US
Practice Address - Phone:808-347-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH00826648343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)