Basic Information
| Provider Information | |||||||||
| NPI: | 1215375092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMEYER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 W WACKER DR | ||||||||
| Address2: | SUITE 1020 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606061216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126400329 | ||||||||
| FaxNumber: | 3126400407 | ||||||||
| Practice Location | |||||||||
| Address1: | 3160 8TH ST SW | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALTOONA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500091023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159674580 | ||||||||
| FaxNumber: | 5159674899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2013 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 005194 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.