Provider Demographics
NPI:1295042307
Name:SUPPNICK, DANIEL (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:SUPPNICK
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 1:12405 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6109
Mailing Address - Country:US
Mailing Address - Phone:503-620-4880
Mailing Address - Fax:
Practice Address - Street 1:12405 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6109
Practice Address - Country:US
Practice Address - Phone:503-620-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4034111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor