Healthcare Provider Details

I. General information

NPI: 1528149499
Provider Name (Legal Business Name): DARYL G KOWALIK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25431 TRABUCO RD 4
LAKE FOREST CA
92630-2787
US

IV. Provider business mailing address

25431 TRABUCO RD STE 4
LAKE FOREST CA
92630-2779
US

V. Phone/Fax

Practice location:
  • Phone: 949-380-8883
  • Fax: 949-380-1308
Mailing address:
  • Phone: 949-380-8883
  • Fax: 949-380-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC24455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: