MEDICARE: LIS LIEN VIZCAINO DOMINGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	243600629	FL

General Provider Information

NPI Number	:	1124866009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIS LIEN VIZCAINO DOMINGUEZ

Provider Business Mailing Address
First Line	:	1513 ORANGE AVE
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-4740
Country	:	US
Telephone Number	:	407-748-8020
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 ORANGE AVE
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-4740
Country	:	US
Telephone Number	:	407-748-8020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2024
Last Update Date	:	07/16/2024

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