Healthcare Provider Details

I. General information

NPI: 1447114004
Provider Name (Legal Business Name): MR. DANIIL DYCHOK SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8744 TONDELLA WAY
FAIR OAKS CA
95628-3925
US

IV. Provider business mailing address

101 CREEKSIDE RIDGE CT
ROSEVILLE CA
95678-3595
US

V. Phone/Fax

Practice location:
  • Phone: 913-414-6219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: