Healthcare Provider Details

I. General information

NPI: 1518872068
Provider Name (Legal Business Name): KEVIN HAROLD DOMINIQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 S HIGHLANDS AVE
SEBRING FL
33870-5416
US

IV. Provider business mailing address

20610 NW 2ND CT
MIAMI FL
33169-2517
US

V. Phone/Fax

Practice location:
  • Phone: 863-385-6101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: