Provider Demographics
NPI:1104185032
Name:DOMENECH, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:DOMENECH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3437
Mailing Address - Country:US
Mailing Address - Phone:631-661-3930
Mailing Address - Fax:
Practice Address - Street 1:116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3437
Practice Address - Country:US
Practice Address - Phone:631-661-3930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-12
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker