Healthcare Provider Details

I. General information

NPI: 1689451148
Provider Name (Legal Business Name): ANDREW BLAKE DAVIS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 TRICORN RD
DANVILLE WV
25053-7148
US

IV. Provider business mailing address

464 3RD ST
MADISON WV
25130-1435
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-1385
  • Fax:
Mailing address:
  • Phone: 304-654-5185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002490
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: