Provider Demographics
NPI:1891334140
Name:GO, DOMINIC MYLES D (RPT)
Entity Type:Individual
Prefix:
First Name:DOMINIC MYLES
Middle Name:D
Last Name:GO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5642 N MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6417
Mailing Address - Country:US
Mailing Address - Phone:224-858-3081
Mailing Address - Fax:
Practice Address - Street 1:5642 N MAJOR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6417
Practice Address - Country:US
Practice Address - Phone:224-858-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty