MEDICARE: MR. JEFFREY TODD DAVIS LAT

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	2255A2300X	Athletic Trainer	AT1069	TX

General Provider Information

NPI Number	:	1760507727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY TODD DAVIS LAT

Provider Business Mailing Address
First Line	:	3206 MONA DR
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-6040
Country	:	US
Telephone Number	:	903-234-8911
Fax Number	:	903-668-5990

Provider Business Practice Location Address
First Line	:	#1 BOBCAT LANE
Second Line	:
City	:	HALLSVILLE
State	:	TX
Zip	:	75650-0810
Country	:	US
Telephone Number	:	903-668-5990
Fax Number	:	903-668-5990

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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