Provider Demographics
NPI:1104367192
Name:DIMINO, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:DIMINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-6053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:608-575-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI2457-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program