Healthcare Provider Details

I. General information

NPI: 1376996355
Provider Name (Legal Business Name): DARYL HEAD B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

IV. Provider business mailing address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

V. Phone/Fax

Practice location:
  • Phone: 573-747-2424
  • Fax: 573-756-4316
Mailing address:
  • Phone: 573-747-2424
  • Fax: 573-756-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: