Provider Demographics
NPI:1790014108
Name:VINCENT DOMINGO DC CSCS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:VINCENT DOMINGO DC CSCS PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-472-0700
Mailing Address - Street 1:1255 W DIVERSEY PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1111
Mailing Address - Country:US
Mailing Address - Phone:773-472-0700
Mailing Address - Fax:
Practice Address - Street 1:1255 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1201
Practice Address - Country:US
Practice Address - Phone:773-472-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010182111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11487753OtherCAQH
IL7296704OtherAETNA
IL9386175OtherPHCS
IL668809OtherUNITED HEALTHCARE
ILP00299763OtherRAILROAD MEDICARE PIN
IL7199662OtherCIGNA
IL01635354OtherBLUE CROSS BLUE SHIELD
ILDE5467OtherRAILROAD MEDICARE GROUP
IL11487753OtherCAQH
ILDE5467OtherRAILROAD MEDICARE GROUP