MEDICARE: PEDRO ENRIQUE DOMINGUEZ SANTANA

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		FL

General Provider Information

NPI Number	:	1558184846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEDRO ENRIQUE DOMINGUEZ SANTANA

Provider Business Mailing Address
First Line	:	777 SW 111TH WAY APT 203
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-6929
Country	:	US
Telephone Number	:	954-446-4391
Fax Number	:

Provider Business Practice Location Address
First Line	:	777SW 111TH WAY
Second Line	:	APTO 203 BUILDING 8
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-3302
Country	:	US
Telephone Number	:	954-446-4391
Fax Number	:

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

Provider Enumeration Date	:	11/05/2024
Last Update Date	:	11/05/2024

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Directions to “ PEDRO ENRIQUE DOMINGUEZ SANTANA ” Practice Location

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