Healthcare Provider Details

I. General information

NPI: 1427974054
Provider Name (Legal Business Name): HUMBERTO DOMINGUEZ LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 E CHERRY LN
CEDAR MI
49621-9411
US

IV. Provider business mailing address

PO BOX 234
LAKE LEELANAU MI
49653-0234
US

V. Phone/Fax

Practice location:
  • Phone: 231-633-5905
  • Fax:
Mailing address:
  • Phone: 231-883-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: