Provider Demographics
NPI:1306403316
Name:BARBO, DOMENICK (LAC)
Entity type:Individual
Prefix:
First Name:DOMENICK
Middle Name:
Last Name:BARBO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S ROSEMEAD BLVD APT 17
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-5677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2602
Practice Address - Country:US
Practice Address - Phone:808-295-7752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73794225700000X
CA19336171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist