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General NPI Number Information
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NPI Number | 1386972867
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Entity Type | Individual
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Provider Name | IVAN DOMENECH
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Gender | Male
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Dates
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Enumeration Date | 11/23/2009
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Last Update Date | 11/23/2009
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Provider Practice Location Address
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Address Line | 103 GOSSMAN RD
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-2225
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Country | US
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Telephone | 910-246-1158
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Fax |
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Provider Business Mailing Address
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Address Line | 55 BLUE PINE DR
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City | SPRING LAKE
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State | NC
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Zip | 28390-9176
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Country | US
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Telephone | 910-814-2726
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 4278
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License Number State | NC
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