Provider Demographics
NPI:1275517807
Name:DOMER CHIROPRACTIC WELLNESS CENTER PC INC
Entity Type:Organization
Organization Name:DOMER CHIROPRACTIC WELLNESS CENTER PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACKARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:JENNICHES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:412-828-4383
Mailing Address - Street 1:426 ALLEGHENY RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15139-1725
Mailing Address - Country:US
Mailing Address - Phone:412-828-4383
Mailing Address - Fax:
Practice Address - Street 1:426 ALLEGHENY RIVER BLVD
Practice Address - Street 2:
Practice Address - City:OAKMONT
Practice Address - State:PA
Practice Address - Zip Code:15139-1725
Practice Address - Country:US
Practice Address - Phone:412-828-4383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008006L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA064668Medicare ID - Type Unspecified