Provider Demographics
NPI:1457805566
Name:PERRY-DOMRES, REBECCA ROSE (DC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ROSE
Last Name:PERRY-DOMRES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 3RD AVE SW STE F
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4346
Mailing Address - Country:US
Mailing Address - Phone:701-721-9616
Mailing Address - Fax:
Practice Address - Street 1:1105 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-1643
Practice Address - Country:US
Practice Address - Phone:701-721-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1033111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor