MEDICARE: PRESTON LEE DAVIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst
2	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1013214436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRESTON LEE DAVIS

Provider Business Mailing Address
First Line	:	PO BOX 270886
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89127-4886
Country	:	US
Telephone Number	:	702-561-9859
Fax Number	:

Provider Business Practice Location Address
First Line	:	2881 N RANCHO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3318
Country	:	US
Telephone Number	:	702-561-9859
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2011
Last Update Date	:	02/21/2011

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