=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881968444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH Y. DAVIS D.C.P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2012
-----------------------------------------------------
Last Update Date | 09/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 363 BLOOMFIELD AVE SUITE 2E
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-744-7447
-----------------------------------------------------
Fax | 973-744-7449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 363 BLOOMFIELD AVE SUITE 2E
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-744-7447
-----------------------------------------------------
Fax | 973-744-7449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KENNETH YALE DAVIS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 973-744-7447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number | 38MC00160000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------