Healthcare Provider Details

I. General information

NPI: 1326733072
Provider Name (Legal Business Name): DANIEL CISCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 WILLIAMSBURG LANDING DR
WILLIAMSBURG VA
23185-3779
US

IV. Provider business mailing address

1511 HAVEN CREST DR
POWDER SPRINGS GA
30127-4961
US

V. Phone/Fax

Practice location:
  • Phone: 800-544-5517
  • Fax:
Mailing address:
  • Phone: 478-918-4093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: