Provider Demographics
NPI:1760587364
Name:DIDOMENICANTONIO, DOMENIC (DC)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:
Last Name:DIDOMENICANTONIO
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 1:3445 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6658
Mailing Address - Country:US
Mailing Address - Phone:310-325-3044
Mailing Address - Fax:
Practice Address - Street 1:3445 PACIFIC COAST HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6658
Practice Address - Country:US
Practice Address - Phone:310-325-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27596111N00000X, 111NS0005X, 111NX0100X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV01519Medicare ID - Type Unspecified