Healthcare Provider Details

I. General information

NPI: 1225151970
Provider Name (Legal Business Name): MR. DARYL FAGAN I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 BROADRICK DR
DALTON GA
30720-2504
US

IV. Provider business mailing address

45 BOXER LN
ROCK SPRING GA
30739-8016
US

V. Phone/Fax

Practice location:
  • Phone: 706-272-6199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 001546
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: