Individual
IVAN DOMENECH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
103 GOSSMAN RD, SOUTHERN PINES, NC 28387-2225
(910) 246-1158
Mailing address
55 BLUE PINE DR, SPRING LAKE, NC 28390-9176
(910) 814-2726
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
4278
NC
Other
Enumeration date
11/23/2009
Last updated
11/23/2009
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