Provider Demographics
NPI:1467481143
Name:STO DOMINGO, MARVIN SALAMANCA (PT)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:SALAMANCA
Last Name:STO DOMINGO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 CHESTERFIELD HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520
Mailing Address - Country:US
Mailing Address - Phone:843-320-8000
Mailing Address - Fax:843-320-8002
Practice Address - Street 1:309 CHESTERFIELD HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520
Practice Address - Country:US
Practice Address - Phone:843-320-8000
Practice Address - Fax:843-320-8002
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3247Medicaid
SCGP3247Medicaid
SCQ326578085Medicare PIN