Provider Demographics
NPI:1720638646
Name:DACHAO, VAGNER CARVALHO (PTA, OPTA)
Entity type:Individual
Prefix:MR
First Name:VAGNER
Middle Name:CARVALHO
Last Name:DACHAO
Suffix:
Gender:M
Credentials:PTA, OPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9642 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1870
Mailing Address - Country:US
Mailing Address - Phone:301-300-8136
Mailing Address - Fax:
Practice Address - Street 1:1201 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7081
Practice Address - Country:US
Practice Address - Phone:805-735-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49677225200000X
TX2142830225200000X
MDA4396225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant