Provider Demographics
NPI:1083625545
Name:CUSANO, DOMENIC ANTHONY JR (DC)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:ANTHONY
Last Name:CUSANO
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MORGAN LANE
Mailing Address - Street 2:
Mailing Address - City:FOX RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60021
Mailing Address - Country:US
Mailing Address - Phone:773-631-0660
Mailing Address - Fax:773-631-1869
Practice Address - Street 1:6580 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1415
Practice Address - Country:US
Practice Address - Phone:773-631-0660
Practice Address - Fax:773-631-1869
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-05961111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1682289OtherBCBS PROVIDER NUMBER
IL901080Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER