Provider Demographics
NPI:1003164385
Name:STEPHEN M. DAQUINO, DO; INC
Entity Type:Organization
Organization Name:STEPHEN M. DAQUINO, DO; INC
Other - Org Name:REVIVIFY RESTORATIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:858-429-0099
Mailing Address - Street 1:16445 BERNARDO CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2523
Mailing Address - Country:US
Mailing Address - Phone:858-429-0099
Mailing Address - Fax:866-266-8027
Practice Address - Street 1:16445 BERNARDO CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2523
Practice Address - Country:US
Practice Address - Phone:858-429-0099
Practice Address - Fax:858-676-1172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8442207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty