Provider Demographics
NPI:1194175687
Name:DOMOLECZNY, DANIEL (LAC)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:DOMOLECZNY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3309
Mailing Address - Country:US
Mailing Address - Phone:773-454-3922
Mailing Address - Fax:
Practice Address - Street 1:193 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3309
Practice Address - Country:US
Practice Address - Phone:773-454-3922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001315171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist