MEDICARE: MR. CLAY BRECKINRIDGE DAULTON L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC19545	CA

General Provider Information

NPI Number	:	1609593706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLAY BRECKINRIDGE DAULTON L.AC.

Provider Business Mailing Address
First Line	:	1813 WILL SCARLET LN
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4618
Country	:	US
Telephone Number	:	707-547-7014
Fax Number	:

Provider Business Practice Location Address
First Line	:	1435 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4505
Country	:	US
Telephone Number	:	707-547-7014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2022
Last Update Date	:	10/20/2022

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