Healthcare Provider Details

I. General information

NPI: 1114759958
Provider Name (Legal Business Name): MARCO ANTONIO DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5478 WILSHIRE BLVD STE 215
LOS ANGELES CA
90036-4225
US

IV. Provider business mailing address

PO BOX 34213
LOS ANGELES CA
90034-0213
US

V. Phone/Fax

Practice location:
  • Phone: 267-897-0264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number138795
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: