Provider Demographics
NPI:1235724477
Name:DOMINGUEZ, LUIS ROBERTO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ROBERTO
Last Name:DOMINGUEZ
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 1:84 HARVARD DR
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-2020
Mailing Address - Country:US
Mailing Address - Phone:914-262-7429
Mailing Address - Fax:
Practice Address - Street 1:84 HARVARD DR
Practice Address - Street 2:
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-2020
Practice Address - Country:US
Practice Address - Phone:914-262-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist