Healthcare Provider Details

I. General information

NPI: 1871186304
Provider Name (Legal Business Name): BRYAN JOSEPH DOMITRZ ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N PARKSIDE RD
NORMAL IL
61761-2780
US

IV. Provider business mailing address

W792 POTTERS CIR
EAST TROY WI
53120-2317
US

V. Phone/Fax

Practice location:
  • Phone: 309-557-4402
  • Fax:
Mailing address:
  • Phone: 414-828-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.004969
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: