Provider Demographics
NPI:1902082100
Name:VINCENT DOMINGO DC SC
Entity Type:Organization
Organization Name:VINCENT DOMINGO DC SC
Other - Org Name:PERFORMANCE HEALTH MEDICAL & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-671-0555
Mailing Address - Street 1:3545 N ROSE STREET
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131
Mailing Address - Country:US
Mailing Address - Phone:847-671-0555
Mailing Address - Fax:847-671-0685
Practice Address - Street 1:3545 N ROSE STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131
Practice Address - Country:US
Practice Address - Phone:847-671-0555
Practice Address - Fax:847-671-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K19177OtherMEMBER
IL01635354OtherBCBS
ILV05866Medicare UPIN