Healthcare Provider Details

I. General information

NPI: 1609328517
Provider Name (Legal Business Name): DANIEL BURCIAGA A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9915 N MAGNOLIA AVE
SANTEE CA
92071
US

IV. Provider business mailing address

2501 RIDGE VIEW DR
SAN DIEGO CA
92105
US

V. Phone/Fax

Practice location:
  • Phone: 619-956-0200
  • Fax:
Mailing address:
  • Phone: 619-788-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000018651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: