Healthcare Provider Details

I. General information

NPI: 1740110345
Provider Name (Legal Business Name): RANDY DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 W INDIANTOWN RD
JUPITER FL
33458-7546
US

IV. Provider business mailing address

1040 DEER RIDGE DR APT 510
BALTIMORE MD
21210-2573
US

V. Phone/Fax

Practice location:
  • Phone: 561-745-1002
  • Fax:
Mailing address:
  • Phone: 561-379-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4441
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA011438
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: