Healthcare Provider Details

I. General information

NPI: 1275694242
Provider Name (Legal Business Name): LUIS F. DOMENECH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 EAST EMPIRE AVENUE
BENTON HARBOR MI
49022-2037
US

IV. Provider business mailing address

21333 HAGGERTY RD. SUITE 150
NOVI MI
48375-5514
US

V. Phone/Fax

Practice location:
  • Phone: 800-979-9595
  • Fax: 248-662-9845
Mailing address:
  • Phone: 248-662-0250
  • Fax: 248-662-9845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301077232
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9465
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: