Healthcare Provider Details

I. General information

NPI: 1154245561
Provider Name (Legal Business Name): DOMINIC DUTTON LAT, ATC, EMT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 R ST
LINCOLN NE
68588-0007
US

IV. Provider business mailing address

6740 SW 4TH ST
LINCOLN NE
68523-9112
US

V. Phone/Fax

Practice location:
  • Phone: 330-469-4772
  • Fax:
Mailing address:
  • Phone: 330-469-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1314
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: