=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093270688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY LORNE HAYNES D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2019
-----------------------------------------------------
Last Update Date | 12/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3775 BEACON AVE. SUITE 200
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-371-5124
-----------------------------------------------------
Fax | 949-655-7873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3775 BEACON AVE. SUITE 200
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-371-5124
-----------------------------------------------------
Fax | 949-655-7873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC34285
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------