Healthcare Provider Details

I. General information

NPI: 1477269678
Provider Name (Legal Business Name): ELLISHA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 LOWNDES HILL RD STE E
GREENVILLE SC
29607-2117
US

IV. Provider business mailing address

811 PENDLETON ST STE 2B
GREENVILLE SC
29601-3232
US

V. Phone/Fax

Practice location:
  • Phone: 864-775-4900
  • Fax:
Mailing address:
  • Phone: 864-775-4900
  • Fax: 864-751-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number38404
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: