Healthcare Provider Details

I. General information

NPI: 1548087752
Provider Name (Legal Business Name): CHARLES EDWARD DAVIS MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 REEVES WAY
CLEMSON SC
29634-0001
US

IV. Provider business mailing address

897 DANBURY WAY
COLUMBIANA OH
44408-9388
US

V. Phone/Fax

Practice location:
  • Phone: 330-501-5797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2291
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: