=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245303221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVIS FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 01/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 MARION AVE
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44903-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-756-7500
-----------------------------------------------------
Fax | 419-525-0001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 MARION AVE
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44903-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-756-7500
-----------------------------------------------------
Fax | 419-525-0001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SABRINA L DAVIS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 419-756-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------