Healthcare Provider Details

I. General information

NPI: 1700408630
Provider Name (Legal Business Name): DANIEL DATU BACULI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38660 LEXINGTON ST APT 588
FREMONT CA
94536-6201
US

IV. Provider business mailing address

38660 LEXINGTON ST APT 588
FREMONT CA
94536-6201
US

V. Phone/Fax

Practice location:
  • Phone: 498-261-2801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number11206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: