Provider Demographics
NPI:1568073948
Name:DOMECH, LUCIANO
Entity Type:Individual
Prefix:
First Name:LUCIANO
Middle Name:
Last Name:DOMECH
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 1:12556 NW 11TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2476
Mailing Address - Country:US
Mailing Address - Phone:786-443-5890
Mailing Address - Fax:
Practice Address - Street 1:12556 NW 11TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-2476
Practice Address - Country:US
Practice Address - Phone:786-443-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-118216106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106400600Medicaid