Healthcare Provider Details

I. General information

NPI: 1518030329
Provider Name (Legal Business Name): MICHAEL EDWARD DAVIS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 DALE RD
MODESTO CA
95356
US

IV. Provider business mailing address

3609 DIX LN
MODESTO CA
95356-1747
US

V. Phone/Fax

Practice location:
  • Phone: 209-735-4048
  • Fax:
Mailing address:
  • Phone: 209-527-2658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 00635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: