Provider Demographics
NPI:1871196816
Name:HUMBLE, DOMINIC VINCENT
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:VINCENT
Last Name:HUMBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 DICKERSON RD
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-4223
Mailing Address - Country:US
Mailing Address - Phone:440-343-8018
Mailing Address - Fax:440-585-3104
Practice Address - Street 1:688 DICKERSON RD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4223
Practice Address - Country:US
Practice Address - Phone:440-343-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver