Healthcare Provider Details

I. General information

NPI: 1285201442
Provider Name (Legal Business Name): ANTHONY D DAVIS TARGETED CASE MANAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 DUPONT CIR STE 226
ST MATTHEWS KY
40207-4847
US

IV. Provider business mailing address

9905 BLUE LICK RD
LOUISVILLE KY
40229-1843
US

V. Phone/Fax

Practice location:
  • Phone: 502-896-8006
  • Fax:
Mailing address:
  • Phone: 502-822-9936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: