Healthcare Provider Details

I. General information

NPI: 1689097420
Provider Name (Legal Business Name): DOMONIQUE GOMES P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34921 US HIGHWAY 19 N
PALM HARBOR FL
34684-1969
US

IV. Provider business mailing address

34921 US HIGHWAY 19 N
PALM HARBOR FL
34684-1969
US

V. Phone/Fax

Practice location:
  • Phone: 800-251-8998
  • Fax:
Mailing address:
  • Phone: 800-251-8998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberPTA24533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: