Provider Demographics
NPI:1922494509
Name:DOMINIQUE, PARKER
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 NE 26TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1538
Mailing Address - Country:US
Mailing Address - Phone:305-450-7739
Mailing Address - Fax:
Practice Address - Street 1:2250 SW 71ST TER
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33317-7136
Practice Address - Country:US
Practice Address - Phone:305-450-7739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33251111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician