1568444966 NPI number — EVELYN DOMINGUEZ

Table of content: EVELYN DOMINGUEZ (NPI 1568444966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568444966 NPI number — EVELYN DOMINGUEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
EVELYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568444966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10131 W. FOREST HILL BLVD
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-798-6600
Provider Business Mailing Address Fax Number:
561-204-2042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 N STATE ROAD 7 STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYAL PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33411-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-798-6600
Provider Business Practice Location Address Fax Number:
561-753-3328
Provider Enumeration Date:
11/19/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN9458773 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246ZS0410X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: APRN11014312 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111129900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".