Healthcare Provider Details

I. General information

NPI: 1023504230
Provider Name (Legal Business Name): DALTON ALAN DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 VICTORY PKWY UNIT 1
CINCINNATI OH
45207-1092
US

IV. Provider business mailing address

2215 VICTORY PKWY APT D5
CINCINNATI OH
45206-2831
US

V. Phone/Fax

Practice location:
  • Phone: 513-745-3000
  • Fax:
Mailing address:
  • Phone: 614-905-9057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: