Healthcare Provider Details

I. General information

NPI: 1013547611
Provider Name (Legal Business Name): LIZDANY CUELLO DOMINGUEZ SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12212 LARCHMERE BLVD
CLEVELAND OH
44120-1102
US

IV. Provider business mailing address

12212 LARCHMERE BLVD
CLEVELAND OH
44120-1102
US

V. Phone/Fax

Practice location:
  • Phone: 216-507-3309
  • Fax:
Mailing address:
  • Phone: 216-507-3309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-454
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: