Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | 00G451440 | CA |
N | 207QA0401X | Family Doctor - Addiction Medicine | G45144 | CA |
NPI | 1770649816 |
---|---|
Provider Name | Mr. Daniel J Headrick |
First Address | Huntington Beach, CA 92615-6747 |
Second Address | San Juan Capistrano, CA 92675-4512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/12/2006 |
Last Update Date | 23/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A49909 | (02) | CA |