Healthcare Provider Details

I. General information

NPI: 1699691857
Provider Name (Legal Business Name): SHANE BRINSON DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W GREEN ST
ATHENS GA
30602-5036
US

IV. Provider business mailing address

231 JENKINS CEMETARY RD
SARDIS GA
30456-2301
US

V. Phone/Fax

Practice location:
  • Phone: 706-542-1911
  • Fax:
Mailing address:
  • Phone: 706-871-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPHI-023934
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: