Provider Demographics
NPI:1366953895
Name:DOMINGUEZ COMMUNITY CENTER CORP.
Entity type:Organization
Organization Name:DOMINGUEZ COMMUNITY CENTER CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADANNYS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-744-4525
Mailing Address - Street 1:13205 SW 137TH AVE STE 132
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5334
Mailing Address - Country:US
Mailing Address - Phone:786-478-6369
Mailing Address - Fax:786-429-1704
Practice Address - Street 1:13205 SW 137TH AVE STE 132
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5334
Practice Address - Country:US
Practice Address - Phone:786-478-6369
Practice Address - Fax:786-429-1704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOMINGUEZ COMMUNITY CENTER CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-24
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022727100Medicaid