Provider Demographics
NPI:1548547706
Name:ROBERT J. DIDOMENICO, D.C., P.C.
Entity type:Organization
Organization Name:ROBERT J. DIDOMENICO, D.C., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIDOMENICO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-664-9060
Mailing Address - Street 1:711 W. NORTH AVENUE
Mailing Address - Street 2:201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1042
Mailing Address - Country:US
Mailing Address - Phone:312-664-9060
Mailing Address - Fax:
Practice Address - Street 1:711 W. NORTH AVE
Practice Address - Street 2:201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1042
Practice Address - Country:US
Practice Address - Phone:312-664-9060
Practice Address - Fax:312-664-9181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201215Medicare UPIN