MEDICARE: THOMAS ALAN DOMINO PT, SCS, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251S0007X	Sports Physical Therapist	1108686	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8T1156	OTHER		BCBS

General Provider Information

NPI Number	:	1013019041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS ALAN DOMINO PT, SCS, CSCS

Provider Business Mailing Address
First Line	:	3531 DELFORD DR
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-1290
Country	:	US
Telephone Number	:	214-387-0552
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 OHIO DR STE 110
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-5331
Country	:	US
Telephone Number	:	972-985-2622
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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