Healthcare Provider Details

I. General information

NPI: 1003661240
Provider Name (Legal Business Name): MADISON DACEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E AVENIDA PICO STE M
SAN CLEMENTE CA
92672-3800
US

IV. Provider business mailing address

2600 DALLAS PKWY STE 290 STE 290
FRISCO TX
75034-7493
US

V. Phone/Fax

Practice location:
  • Phone: 949-245-6581
  • Fax:
Mailing address:
  • Phone: 508-385-4212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27864
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: