Healthcare Provider Details

I. General information

NPI: 1154912574
Provider Name (Legal Business Name): DOMINIC ILARDI PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 S 144TH ST STE 212
OMAHA NE
68144-5253
US

IV. Provider business mailing address

2725 S 144TH ST STE 212
OMAHA NE
68144-5253
US

V. Phone/Fax

Practice location:
  • Phone: 402-609-3000
  • Fax: 402-609-3808
Mailing address:
  • Phone: 402-609-3000
  • Fax: 402-609-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number018186
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4184
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: