Healthcare Provider Details

I. General information

NPI: 1689647208
Provider Name (Legal Business Name): JOHN L DAVIS MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MONTCLAIR STATE UNIVERSITY 1 NORMAL AVE.
MONTCLAIR NJ
07043-1624
US

IV. Provider business mailing address

22 HILTON ST
PEQUANNOCK NJ
07440-1311
US

V. Phone/Fax

Practice location:
  • Phone: 973-655-5250
  • Fax: 973-655-5436
Mailing address:
  • Phone: 973-633-8010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number25MT00010700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: