Provider Demographics
NPI:1104195569
Name:SANDOMINGO, MANUEL (LMT)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:SANDOMINGO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 CORAL WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-6541
Mailing Address - Country:US
Mailing Address - Phone:786-334-5290
Mailing Address - Fax:786-334-5292
Practice Address - Street 1:7815 CORAL WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6541
Practice Address - Country:US
Practice Address - Phone:786-334-5290
Practice Address - Fax:786-334-5292
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA64742225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist