MEDICARE: DOMINIQUE FREEMAN

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	1744P3200X	Prosthetics Case Management	CL1216296	FL

General Provider Information

NPI Number	:	1700344306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE FREEMAN

Provider Business Mailing Address
First Line	:	439 CORTEZ RD W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34207-1544
Country	:	US
Telephone Number	:	941-284-6733
Fax Number	:

Provider Business Practice Location Address
First Line	:	439 CORTEZ RD W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34207-1544
Country	:	US
Telephone Number	:	941-284-6733
Fax Number	:

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

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	03/04/2019

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