=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447144068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. DALLAS R DAVIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2025
-----------------------------------------------------
Last Update Date | 11/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5473 KEARNY VILLA RD STE 300
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-605-9393
-----------------------------------------------------
Fax | 619-684-7004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5473 KEARNY VILLA RD STE 300
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-605-9393
-----------------------------------------------------
Fax | 619-684-7004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 21055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------