Healthcare Provider Details

I. General information

NPI: 1154874816
Provider Name (Legal Business Name): DANIEL M DAVIS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DAVIS STUART RD
RONCEVERTE WV
24970-9549
US

IV. Provider business mailing address

111 DAVIS STUART RD
RONCEVERTE WV
24970-9549
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-3987
  • Fax: 304-647-3990
Mailing address:
  • Phone: 304-647-3987
  • Fax: 304-647-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 003668
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: