Healthcare Provider Details

I. General information

NPI: 1104367192
Provider Name (Legal Business Name): CHRISTOPHER DIMINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E LAYTON AVE
SAINT FRANCIS WI
53235-6053
US

IV. Provider business mailing address

4202 W OAKWOOD PARK CT
FRANKLIN WI
53132-9118
US

V. Phone/Fax

Practice location:
  • Phone: 608-575-2799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2457-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: