Individual
BEAU FABACHER DOMANGUE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
6245 INKSTER RD, GARDEN CITY, MI 48135-4001
(504) 512-5203
Mailing address
6447 LAKEVIEW BLVD APT 9308, WESTLAND, MI 48185-5848
(504) 512-5203
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
329233
LA
207P00000X
Emergency Medicine Physician
4301506642
MI
207Q00000X
Family Medicine Physician
329233
LA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
13037585
—
LA
01
—
5315236518
CDS LICENSE FROM BOARD OF PHARMACY
MI
Enumeration date
03/31/2018
Last updated
12/16/2024
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