Healthcare Provider Details

I. General information

NPI: 1447676408
Provider Name (Legal Business Name): DAW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W KETTLEMAN LN STE. A
LODI CA
95242-9287
US

IV. Provider business mailing address

4583 PINE VALLEY CIR
STOCKTON CA
95219-1871
US

V. Phone/Fax

Practice location:
  • Phone: 209-481-0091
  • Fax: 209-333-0624
Mailing address:
  • Phone: 209-333-1148
  • Fax: 209-333-0624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCP01776
License Number StateCA

VIII. Authorized Official

Name: DAVID WEYMOUTH
Title or Position: OWNER
Credential: CP
Phone: 209-481-0091