1902082100 NPI number — VINCENT DOMINGO DC SC

Table of content: (NPI 1902082100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902082100 NPI number — VINCENT DOMINGO DC SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINCENT DOMINGO DC SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PERFORMANCE HEALTH MEDICAL & REHAB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902082100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 N ROSE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-671-0555
Provider Business Mailing Address Fax Number:
847-671-0685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3545 N ROSE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-671-0555
Provider Business Practice Location Address Fax Number:
847-671-0685
Provider Enumeration Date:
01/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DOMINGO
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
847-671-0555

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: K19177 . This is a "MEMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01635354 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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