Healthcare Provider Details

I. General information

NPI: 1285061838
Provider Name (Legal Business Name): DAVIS INTEGRATED MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 ORANGE RD
MONTCLAIR NJ
07042-4451
US

IV. Provider business mailing address

309 ORANGE RD
MONTCLAIR NJ
07042-4451
US

V. Phone/Fax

Practice location:
  • Phone: 973-839-1003
  • Fax: 973-839-3653
Mailing address:
  • Phone: 973-839-1003
  • Fax: 973-839-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00206300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number38MC00206300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number38MC00206300
License Number StateNJ

VIII. Authorized Official

Name: ALFRED DAVIS
Title or Position: OWNERQ
Credential: DC
Phone: 973-839-1003