Healthcare Provider Details

I. General information

NPI: 1043845704
Provider Name (Legal Business Name): REBECA ELIZABETH DAVILA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3167 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-1475
US

IV. Provider business mailing address

822 CASS AVE SE
GRAND RAPIDS MI
49507-1116
US

V. Phone/Fax

Practice location:
  • Phone: 773-987-1357
  • Fax: 616-414-8530
Mailing address:
  • Phone: 773-987-1357
  • Fax: 616-414-8530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198000987
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: