Healthcare Provider Details

I. General information

NPI: 1609365618
Provider Name (Legal Business Name): MARVIN D DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14574 US HIGHWAY 23
WAVERLY OH
45690-9373
US

IV. Provider business mailing address

68 LANE DR
CHILLICOTHEE OH
45601-9110
US

V. Phone/Fax

Practice location:
  • Phone: 740-947-6727
  • Fax:
Mailing address:
  • Phone: 740-804-2714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: