Healthcare Provider Details

I. General information

NPI: 1902370604
Provider Name (Legal Business Name): MR. CAMERON JAMES DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax: 530-626-9240
Mailing address:
  • Phone: 530-626-9240
  • Fax: 530-626-9240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: