Provider Demographics
NPI:1033564505
Name:VICEDOMINI, DOMIGO RENE (HIS)
Entity Type:Individual
Prefix:
First Name:DOMIGO
Middle Name:RENE
Last Name:VICEDOMINI
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2006
Mailing Address - Country:US
Mailing Address - Phone:985-246-9737
Mailing Address - Fax:860-395-4333
Practice Address - Street 1:17 SUNSET RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2006
Practice Address - Country:US
Practice Address - Phone:985-246-9737
Practice Address - Fax:860-395-4333
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT433237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist