Provider Demographics
NPI:1184272866
Name:CONCEPCION, DOMINIC (MT)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:CONCEPCION
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-3146
Mailing Address - Country:US
Mailing Address - Phone:718-710-1981
Mailing Address - Fax:
Practice Address - Street 1:377 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-3146
Practice Address - Country:US
Practice Address - Phone:718-710-1981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01348000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ18KT01348000OtherNJ STATE LICENSE