Healthcare Provider Details

I. General information

NPI: 1316750904
Provider Name (Legal Business Name): DEETTRA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

2703 HARVEY WAY
LAKEWOOD CA
90712-3734
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 562-234-9453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: