Provider Demographics
NPI:1851442271
Name:DESURRA, DANIEL JAMES (LAC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JAMES
Last Name:DESURRA
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 1:980 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9475
Mailing Address - Country:US
Mailing Address - Phone:541-347-9100
Mailing Address - Fax:541-329-0260
Practice Address - Street 1:980 2ND ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9475
Practice Address - Country:US
Practice Address - Phone:541-347-9100
Practice Address - Fax:541-329-0260
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00826171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist