Provider Demographics
NPI:1790920387
Name:DOMINGUEZ, ELVIS (EMT)
Entity Type:Individual
Prefix:MR
First Name:ELVIS
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:HC 03 BOX 18685, LAJAS, P.R. 00667
Mailing Address - Street 2:
Mailing Address - City:LAJAS
Mailing Address - State:PR
Mailing Address - Zip Code:00667
Mailing Address - Country:US
Mailing Address - Phone:787-673-4836
Mailing Address - Fax:
Practice Address - Street 1:HC 3 BOX 18685
Practice Address - Street 2:
Practice Address - City:LAJAS
Practice Address - State:PR
Practice Address - Zip Code:00667-9624
Practice Address - Country:US
Practice Address - Phone:787-673-4836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4663109347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle