Healthcare Provider Details

I. General information

NPI: 1245742063
Provider Name (Legal Business Name): DAULTON DAIES ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N 2ND ST
ATCHISON KS
66002-1402
US

IV. Provider business mailing address

216 N 7TH ST
ATCHISON KS
66002-2427
US

V. Phone/Fax

Practice location:
  • Phone: 636-487-1160
  • Fax: 636-487-1160
Mailing address:
  • Phone: 636-487-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number24-01252
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: