Provider Demographics
NPI:1922498518
Name:DOMANTAY, CHANDA
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:
Last Name:DOMANTAY
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 1:915 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-4514
Mailing Address - Country:US
Mailing Address - Phone:415-777-9953
Mailing Address - Fax:415-777-4717
Practice Address - Street 1:915 BRYANT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-4514
Practice Address - Country:US
Practice Address - Phone:415-777-9953
Practice Address - Fax:415-777-4717
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81828183700000X, 251S00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No183700000XPharmacy Service ProvidersPharmacy Technician
No251S00000XAgenciesCommunity/Behavioral Health