Healthcare Provider Details

I. General information

NPI: 1033998810
Provider Name (Legal Business Name): EDGAR DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 07/13/2025
Certification Date: 07/13/2025
Deactivation Date: 06/05/2024
Reactivation Date: 08/01/2024

III. Provider practice location address

4121 LITTLE SAVANNAH RD
CULLOWHEE NC
28723
US

IV. Provider business mailing address

7918 WILLOWS POND CT
CHARLOTTE NC
28277-8408
US

V. Phone/Fax

Practice location:
  • Phone: 704-954-4815
  • Fax:
Mailing address:
  • Phone: 858-375-9176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-5809
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: