Healthcare Provider Details

I. General information

NPI: 1780891770
Provider Name (Legal Business Name): VIVIAN L DAVIS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 DAWSON RD
ALBANY GA
31707
US

IV. Provider business mailing address

1534 DAWSON RD
ALBANY GA
31707
US

V. Phone/Fax

Practice location:
  • Phone: 229-435-9008
  • Fax: 229-435-9080
Mailing address:
  • Phone: 229-435-9008
  • Fax: 229-435-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT000009
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA10936
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number28341600 NATL CERTIF
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: