MEDICARE: LUIS MIGUEL FUENTES DOMINGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699585919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS MIGUEL FUENTES DOMINGUEZ

Provider Business Mailing Address
First Line	:	7001 SANDHURST DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-5946
Country	:	US
Telephone Number	:	813-730-6178
Fax Number	:

Provider Business Practice Location Address
First Line	:	7001 SANDHURST DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-5946
Country	:	US
Telephone Number	:	813-730-6178
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2025
Last Update Date	:	01/09/2025

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Directions to “ LUIS MIGUEL FUENTES DOMINGUEZ ” Practice Location

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