Provider Demographics
NPI:1972298180
Name:DOMINADOR MANSAT JR, A PROFESSIONAL NURSING CORP
Entity type:Organization
Organization Name:DOMINADOR MANSAT JR, A PROFESSIONAL NURSING CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOMINADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSAT
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:909-348-3067
Mailing Address - Street 1:9415 RETREAT PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-9200
Mailing Address - Country:US
Mailing Address - Phone:909-348-2556
Mailing Address - Fax:877-615-1555
Practice Address - Street 1:1910 S ARCHIBALD AVE STE D
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8503
Practice Address - Country:US
Practice Address - Phone:909-348-2556
Practice Address - Fax:877-615-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty