Provider Demographics
NPI:1194409284
Name:GLORIA EDEN G DOMINGO MD LLC
Entity type:Organization
Organization Name:GLORIA EDEN G DOMINGO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA EDEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-222-4111
Mailing Address - Street 1:PO BOX 30460
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96820-0460
Mailing Address - Country:US
Mailing Address - Phone:808-941-3863
Mailing Address - Fax:808-949-0483
Practice Address - Street 1:94-333 WAIPAHU DEPOT ST # M6
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3012
Practice Address - Country:US
Practice Address - Phone:808-677-5664
Practice Address - Fax:808-784-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care