MEDICARE: CHICAGO REGENERATIVE MEDICAL CENTER CORPORATION

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1275186033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO REGENERATIVE MEDICAL CENTER CORPORATION

Provider Business Mailing Address
First Line	:	4149 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4314
Country	:	US
Telephone Number	:	773-562-2632
Fax Number	:

Provider Business Practice Location Address
First Line	:	4149 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4314
Country	:	US
Telephone Number	:	877-542-1110
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. VINCENT DOMINGO
Credential	:	DC
Telephone Number	:	773-562-2632

Provider Enumeration Date	:	07/22/2019
Last Update Date	:	05/26/2020

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