Provider Demographics
NPI:1265937643
Name:MARQUEZ, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:MARQUEZ
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 1:1100 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4151
Mailing Address - Country:US
Mailing Address - Phone:575-769-2345
Mailing Address - Fax:
Practice Address - Street 1:1005 S MONROE ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3208
Practice Address - Country:US
Practice Address - Phone:575-461-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator