Provider Demographics
NPI:1396967600
Name:DOMKE, MARK KENNETH (RKT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:KENNETH
Last Name:DOMKE
Suffix:
Gender:M
Credentials:RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 STONECREEK DR
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-3131
Mailing Address - Country:US
Mailing Address - Phone:707-208-2081
Mailing Address - Fax:
Practice Address - Street 1:765 SERENO DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2415
Practice Address - Country:US
Practice Address - Phone:707-208-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist