Provider Demographics
NPI:1154119352
Name:LOPEZ DOMINGUEZ, ELIEL DAVID
Entity type:Individual
Prefix:
First Name:ELIEL
Middle Name:DAVID
Last Name:LOPEZ DOMINGUEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11378 W FLAGLER ST APT 106
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1190
Mailing Address - Country:US
Mailing Address - Phone:305-904-2835
Mailing Address - Fax:
Practice Address - Street 1:1700 SW 57TH AVE STE 209
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2163
Practice Address - Country:US
Practice Address - Phone:786-558-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician