Healthcare Provider Details

I. General information

NPI: 1902286883
Provider Name (Legal Business Name): KERRY DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 POPPY SEED LOOP
COLUMBUS GA
31907-3071
US

IV. Provider business mailing address

3010 POPPY SEED LOOP
COLUMBUS GA
31907-3071
US

V. Phone/Fax

Practice location:
  • Phone: 706-321-9606
  • Fax:
Mailing address:
  • Phone: 706-321-9606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: