MEDICARE: MR. JACK DAVIS SELLS DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4605	KY

General Provider Information

NPI Number	:	1326075466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK DAVIS SELLS DC

Provider Business Mailing Address
First Line	:	3703 TAYLORSVILLE RD STE 105
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-1330
Country	:	US
Telephone Number	:	502-558-0099
Fax Number	:	502-709-5414

Provider Business Practice Location Address
First Line	:	3703 TAYLORSVILLE RD STE 105
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-1330
Country	:	US
Telephone Number	:	502-558-0099
Fax Number	:	502-709-5414

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	02/25/2020

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