Provider Demographics
NPI:1437397544
Name:RIVERSIDE SURGICAL AND WEIGHT LOSS CENTER,LLC
Entity Type:Organization
Organization Name:RIVERSIDE SURGICAL AND WEIGHT LOSS CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:DOMKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD,FACS
Authorized Official - Phone:772-581-8003
Mailing Address - Street 1:705 SEBASTIAN BLVD.
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958
Mailing Address - Country:US
Mailing Address - Phone:772-581-8003
Mailing Address - Fax:772-581-8005
Practice Address - Street 1:705 SEBASTIAN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-4397
Practice Address - Country:US
Practice Address - Phone:772-581-8003
Practice Address - Fax:772-581-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMD89469208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty