Healthcare Provider Details

I. General information

NPI: 1154059681
Provider Name (Legal Business Name): JOHN DAVID DAVIS LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 MAIN ST
LANDER WY
82520-3036
US

IV. Provider business mailing address

748 MAIN ST
LANDER WY
82520-3036
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2231
  • Fax:
Mailing address:
  • Phone: 307-332-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAT-241
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: