Provider Demographics
NPI:1528175445
Name:DOMINGO, BRYCE KUULEI (PTA, LMP)
Entity type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:KUULEI
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:PTA, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:17833 1ST AVE S STE A
Practice Address - Street 2:
Practice Address - City:NORMANDY PARK
Practice Address - State:WA
Practice Address - Zip Code:98148-1713
Practice Address - Country:US
Practice Address - Phone:253-330-8518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
WAMA00024952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant