Healthcare Provider Details

I. General information

NPI: 1578034757
Provider Name (Legal Business Name): JEFFREY DAGELET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 EL CAMINO REAL
SOUTH SAN FRANCISCO CA
94080-3208
US

IV. Provider business mailing address

PO BOX 3672
SAN LEANDRO CA
94578-0672
US

V. Phone/Fax

Practice location:
  • Phone: 650-742-3182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number17012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: