Healthcare Provider Details

I. General information

NPI: 1164191284
Provider Name (Legal Business Name): DOM THE OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5690 ATLANTIC AVE APT 204
DELRAY BEACH FL
33484-8217
US

IV. Provider business mailing address

5690 ATLANTIC AVE APT 204
DELRAY BEACH FL
33484-8217
US

V. Phone/Fax

Practice location:
  • Phone: 786-390-6614
  • Fax:
Mailing address:
  • Phone: 786-390-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE ALEXIS
Title or Position: OWNER
Credential:
Phone: 786-390-6614