Provider Demographics
NPI:1871019737
Name:DOMINGUEZ, CLARIVEL (WELLNESS COACH)
Entity type:Individual
Prefix:MS
First Name:CLARIVEL
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:WELLNESS COACH
Other - Prefix:MRS
Other - First Name:CLARIVEL
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WELLNESS COACH
Mailing Address - Street 1:13109 CURTIS AND KING RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13109 CURTIS AND KING RD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2152
Practice Address - Country:US
Practice Address - Phone:323-896-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1170064024283XC2000X
CA1501214442133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No283XC2000XHospitalsRehabilitation HospitalChildrenGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE