Healthcare Provider Details

I. General information

NPI: 1043535420
Provider Name (Legal Business Name): JASPER E DAVIS DC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 42ND ST S
FARGO ND
58103-2119
US

IV. Provider business mailing address

900 42ND ST S
FARGO ND
58103-2119
US

V. Phone/Fax

Practice location:
  • Phone: 701-277-5290
  • Fax:
Mailing address:
  • Phone: 701-277-5290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC137
License Number StateND

VIII. Authorized Official

Name: JASPER E DAVIS
Title or Position: DIRECTOR
Credential: DC
Phone: 701-277-5290