Provider Demographics
NPI:1285782789
Name:DOMINGUEZ J-MAR LTD
Entity type:Organization
Organization Name:DOMINGUEZ J-MAR LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAUL
Authorized Official - Middle Name:ESTRADA
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-866-4010
Mailing Address - Street 1:PO BOX 1384
Mailing Address - Street 2:207 E LOOP 193
Mailing Address - City:WOLFFORTH
Mailing Address - State:TX
Mailing Address - Zip Code:79382-1384
Mailing Address - Country:US
Mailing Address - Phone:806-866-4010
Mailing Address - Fax:806-866-4061
Practice Address - Street 1:207 LOOP 193
Practice Address - Street 2:
Practice Address - City:WOLFFORTH
Practice Address - State:TX
Practice Address - Zip Code:79382
Practice Address - Country:US
Practice Address - Phone:806-886-4010
Practice Address - Fax:806-866-4061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX0073642332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91380049Medicaid
NM91380049Medicaid