Healthcare Provider Details

I. General information

NPI: 1174459119
Provider Name (Legal Business Name): ERNEST DOMINGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 MULBERRY LN
IOTA LA
70543-4207
US

IV. Provider business mailing address

231 MULBERRY LN
IOTA LA
70543-4207
US

V. Phone/Fax

Practice location:
  • Phone: 337-223-1555
  • Fax:
Mailing address:
  • Phone: 337-223-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: