Provider Demographics
NPI:1376824201
Name:DEVINE, DANIEL J (LAC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:DEVINE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 GROSS ROAD EXT
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2054
Mailing Address - Country:US
Mailing Address - Phone:831-464-1605
Mailing Address - Fax:
Practice Address - Street 1:4170 GROSS ROAD EXT
Practice Address - Street 2:SUITE 6
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2054
Practice Address - Country:US
Practice Address - Phone:831-464-1605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14080171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist