Provider Demographics
NPI:1396743852
Name:DOMENICK, WAYNE E (DC)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:E
Last Name:DOMENICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9037 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-8869
Mailing Address - Country:US
Mailing Address - Phone:810-636-2190
Mailing Address - Fax:810-636-7855
Practice Address - Street 1:9037 S STATE RD
Practice Address - Street 2:
Practice Address - City:GOODRICH
Practice Address - State:MI
Practice Address - Zip Code:48438-8869
Practice Address - Country:US
Practice Address - Phone:810-636-2190
Practice Address - Fax:810-636-7855
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4724081Medicaid
MI0999848OtherHEALTH PLUS
MI950B514920OtherBCBSM
MI4724081Medicaid
MI0999848OtherHEALTH PLUS
MIV02211Medicare UPIN