Provider Demographics
NPI:1992106454
Name:DANIAL, MARK (DPT, OCS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DANIAL
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1005
Mailing Address - Country:US
Mailing Address - Phone:323-255-5409
Mailing Address - Fax:323-255-5732
Practice Address - Street 1:2560 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE ROCK
Practice Address - State:CA
Practice Address - Zip Code:90041-1005
Practice Address - Country:US
Practice Address - Phone:323-255-5409
Practice Address - Fax:323-255-5732
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379962251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic