Healthcare Provider Details

I. General information

NPI: 1770424608
Provider Name (Legal Business Name): MATTHEW LEE DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9137 E MINERAL CIR UNIT 10
CENTENNIAL CO
80112-3421
US

IV. Provider business mailing address

4868 THORNDIKE AVE
CASTLE ROCK CO
80104-5458
US

V. Phone/Fax

Practice location:
  • Phone: 303-847-0905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0025884
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: