Basic Information
| Provider Information | |||||||||
| NPI: | 1447721774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDRADE | ||||||||
| FirstName: | DOMINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 N JACKSON ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912064330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182416780 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 EXCISE AVE STE 116 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917618557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182416780 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.