Healthcare Provider Details

I. General information

NPI: 1821437062
Provider Name (Legal Business Name): DANIEL WICK C. PED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 ROLLING OAKS DR STE 210
THOUSAND OAKS CA
91361-1088
US

IV. Provider business mailing address

68 DICKENSON AVE
NEWBURY PARK CA
91320-4321
US

V. Phone/Fax

Practice location:
  • Phone: 805-573-4008
  • Fax: 805-446-3140
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT4188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: