Provider Demographics
NPI:1609593706
Name:DAULTON, CLAY BRECKINRIDGE (LAC)
Entity Type:Individual
Prefix:MR
First Name:CLAY
Middle Name:BRECKINRIDGE
Last Name:DAULTON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 WILL SCARLET LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4618
Mailing Address - Country:US
Mailing Address - Phone:707-547-7014
Mailing Address - Fax:
Practice Address - Street 1:1435 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4505
Practice Address - Country:US
Practice Address - Phone:707-547-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19545171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist