Healthcare Provider Details

I. General information

NPI: 1710352919
Provider Name (Legal Business Name): MICHAEL DAVIS MSOT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WINDSOR PATH SUITE 4
GEORGETOWN KY
40324-9610
US

IV. Provider business mailing address

103 WINDSOR PATH SUITE 4
GEORGETOWN KY
40324-9610
US

V. Phone/Fax

Practice location:
  • Phone: 502-863-3870
  • Fax: 502-863-1287
Mailing address:
  • Phone: 502-863-3870
  • Fax: 502-863-1287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberBOTOCT00222802
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: