Healthcare Provider Details

I. General information

NPI: 1740611268
Provider Name (Legal Business Name): JASON DOMICO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 CAMDEN CT
OAK BROOK IL
60523-1272
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301N
OAK BROOK IL
60523-1234
US

V. Phone/Fax

Practice location:
  • Phone: 630-468-1820
  • Fax: 630-701-1007
Mailing address:
  • Phone: 630-320-6400
  • Fax: 630-701-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038012495
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: