Provider Demographics
NPI:1902693492
Name:GARCIA, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:GARCIA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LOG LANE VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80705-4848
Mailing Address - Country:US
Mailing Address - Phone:970-370-8596
Mailing Address - Fax:
Practice Address - Street 1:2015 CLUBHOUSE DR STE 102
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-3651
Practice Address - Country:US
Practice Address - Phone:970-506-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015630225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant