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General NPI Number Information
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NPI Number | 1447753702
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Entity Type | Individual
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Provider Name | COREY GLEN DAVIDSON
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Gender | Male
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Dates
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Enumeration Date | 03/13/2018
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Last Update Date | 03/13/2018
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Provider Practice Location Address
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Address Line | 100 E 13TH ST STE 111
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City | VANCOUVER
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State | WA
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Zip | 98660-3329
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Country | US
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Telephone | 360-521-6090
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Fax |
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Provider Business Mailing Address
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Address Line | 11018 NE 98TH ST
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City | VANCOUVER
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State | WA
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Zip | 98662-2274
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Country | US
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Telephone | 360-213-9405
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 60656485
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License Number State | WA
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