Provider Demographics
NPI:1912966029
Name:DOMIR, ETHEL LORAINE (PT)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:LORAINE
Last Name:DOMIR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 DELAWARE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-1400
Mailing Address - Country:US
Mailing Address - Phone:740-382-1734
Mailing Address - Fax:740-387-6918
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1400
Practice Address - Country:US
Practice Address - Phone:740-382-1734
Practice Address - Fax:740-387-6918
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT002605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO4162391Medicare ID - Type Unspecified