Provider Demographics
NPI:1528149499
Name:KOWALIK, DARYL G (DC)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:G
Last Name:KOWALIK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25431 TRABUCO RD STE 4
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2779
Mailing Address - Country:US
Mailing Address - Phone:949-380-8883
Mailing Address - Fax:949-380-1308
Practice Address - Street 1:25431 TRABUCO RD
Practice Address - Street 2:4
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2787
Practice Address - Country:US
Practice Address - Phone:949-380-8883
Practice Address - Fax:949-380-1308
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06836ZOtherBLUE SHIELD
CAU87408Medicare UPIN
CADC24455Medicare ID - Type Unspecified