Healthcare Provider Details

I. General information

NPI: 1285225037
Provider Name (Legal Business Name): KYANNA L DAGDAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4952 WARNER AVE STE 300
HUNTINGTON BEACH CA
92649-5506
US

IV. Provider business mailing address

4994 N CRESCENT ST
SAN BERNARDINO CA
92407-3022
US

V. Phone/Fax

Practice location:
  • Phone: 510-268-8120
  • Fax:
Mailing address:
  • Phone: 760-554-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: