Healthcare Provider Details

I. General information

NPI: 1710172093
Provider Name (Legal Business Name): DOMICILLIARY SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 VICEROY DR
DALLAS TX
75235-2303
US

IV. Provider business mailing address

1513 VICEROY DR
DALLAS TX
75235-2303
US

V. Phone/Fax

Practice location:
  • Phone: 469-685-7020
  • Fax: 214-920-8446
Mailing address:
  • Phone: 469-685-7020
  • Fax: 214-920-8446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateTX

VIII. Authorized Official

Name: DR. MANUEL S RIVERO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 469-595-9475