Provider Demographics
NPI:1720633050
Name:DOMENDEN, VIRCELITO A I
Entity Type:Individual
Prefix:
First Name:VIRCELITO
Middle Name:A
Last Name:DOMENDEN
Suffix:I
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 1:30685 UNION CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-2546
Mailing Address - Country:US
Mailing Address - Phone:510-502-8589
Mailing Address - Fax:
Practice Address - Street 1:900 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4211
Practice Address - Country:US
Practice Address - Phone:650-293-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)