Basic Information
| Provider Information | |||||||||
| NPI: | 1780973818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMENIGHETTI | ||||||||
| FirstName: | SHIORI | ||||||||
| MiddleName: | MURAI | ||||||||
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| OtherLastName: | MURAI | ||||||||
| OtherFirstName: | SHIORI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3703 WEST LAKE AVENUE, SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3703 WEST LAKE AVENUE, SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | AT9350 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 160.007275 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.