Provider Demographics
NPI:1255731527
Name:DOMINICK, MARK (ATC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DOMINICK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CHESTNUT DR
Mailing Address - Street 2:APARTMENT #3
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7835
Mailing Address - Country:US
Mailing Address - Phone:207-272-6819
Mailing Address - Fax:
Practice Address - Street 1:521 LANCASTER AVE
Practice Address - Street 2:MOBERLY BUILDING
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3100
Practice Address - Country:US
Practice Address - Phone:207-272-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-24
Last Update Date:2014-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer