Provider Demographics
NPI:1114971868
Name:RICCIO, DOMINIC A (DC)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:A
Last Name:RICCIO
Suffix:
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 1:1633 HIGHWAY 35
Mailing Address - Street 2:HIGHWAY 35
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-2970
Mailing Address - Country:US
Mailing Address - Phone:732-531-3636
Mailing Address - Fax:732-531-2099
Practice Address - Street 1:1633 HIGHWAY 35
Practice Address - Street 2:HIGHWAY 35
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-2970
Practice Address - Country:US
Practice Address - Phone:732-531-3636
Practice Address - Fax:732-531-2099
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00357800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22-3749862OtherTAX ID NUMBER
NJRI667724Medicare PIN
NJ22-3749862OtherTAX ID NUMBER