Edgar Antonio Domenech

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

1638 Owen Drive
Fayetteville, NC 28304

Phone

(910) 615-4000

NPI assigned

Jul 16, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1594857600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1680912000000",
    "number": "1770191629",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1638 OWEN DRIVE",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "28304",
            "telephone_number": "910-615-4000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1638 OWEN DRIVE",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "28304",
            "telephone_number": "910-615-4000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "PHSU, 388 Zona Industrial Reparada 2",
            "address_purpose": "LOCATION",
            "city": "Ponce",
            "state": "PR",
            "postal_code": "007167004",
            "country_code": "US",
            "telephone_number": "787-840-2575",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DOMENECH",
        "first_name": "EDGAR",
        "middle_name": "ANTONIO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-07-16",
        "last_updated": "2023-04-08",
        "certification_date": "2023-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Student in an Organized Health Care Education/Training Program in Fayetteville, NC
• Providers in Fayetteville, NC by specialty
• Student in an Organized Health Care Education/Training Program in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.