Healthcare Provider Details

I. General information

NPI: 1861898025
Provider Name (Legal Business Name): MARC DARRELL DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 ATLANTA AVE SUITE D3
RIVERSIDE CA
92507-7419
US

IV. Provider business mailing address

PO BOX 281
SAN JACINTO CA
92581-0281
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-8000
  • Fax: 951-955-8010
Mailing address:
  • Phone: 951-634-0297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: