Basic Information
| Provider Information | |||||||||
| NPI: | 1275694242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMENECH | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21333 HAGGERTY RD. | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486620250 | ||||||||
| FaxNumber: | 2486629845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1385 EAST EMPIRE AVENUE | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490222037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009799595 | ||||||||
| FaxNumber: | 2486629845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301077232 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 9465 | PR | N | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.