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General NPI Number Information
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NPI Number | 1437397544
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Entity Type | Organization
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Legal Business Name | RIVERSIDE SURGICAL AND WEIGHT LOSS CENTER,LLC
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Dates
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Enumeration Date | 01/27/2009
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Last Update Date | 05/07/2009
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Provider Practice Location Address
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Address Line | 705 SEBASTIAN BLVD SUITE D
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City | SEBASTIAN
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State | FL
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Zip | 32958-4397
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Country | US
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Telephone | 772-581-8003
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Fax | 772-581-8005
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Provider Business Mailing Address
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Address Line | 705 SEBASTIAN BLVD. SUITE D
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City | SEBASTIAN
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State | FL
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Zip | 32958
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Country | US
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Telephone | 772-581-8003
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Fax | 772-581-8005
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PATRICK W DOMKOWSKI
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Credential | MD, PHD,FACS
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Telephone | 772-581-8003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD89469
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License Number State | FL
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