Healthcare Provider Details

I. General information

NPI: 1972111870
Provider Name (Legal Business Name): BRENT P DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 3RD AVE
SAN DIEGO CA
92103-1407
US

IV. Provider business mailing address

4309 3RD AVE
SAN DIEGO CA
92103-1407
US

V. Phone/Fax

Practice location:
  • Phone: 619-876-4502
  • Fax:
Mailing address:
  • Phone: 619-876-4502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number584068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: