Healthcare Provider Details

I. General information

NPI: 1720336837
Provider Name (Legal Business Name): STANLEY DOMINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10502 SATELLITE BLVD SUITE D
ORLANDO FL
32837-8479
US

IV. Provider business mailing address

10502 SATELLITE BLVD SUITE D
ORLANDO FL
32837-8479
US

V. Phone/Fax

Practice location:
  • Phone: 407-850-9141
  • Fax: 407-850-9687
Mailing address:
  • Phone: 407-850-9141
  • Fax: 407-850-9687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberIM4999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: