MEDICARE: DR. GREG C. DAVIS D.C.

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	111NS0005X	Sports Physician Chiropractor	4259	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0243840	OTHER	AZ	BLUE CROSS PROVIDER

General Provider Information

NPI Number	:	1336257435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREG C. DAVIS D.C.

Provider Business Mailing Address
First Line	:	2240 MCCULLOCH BLVD N
Second Line	:	STE C
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6904
Country	:	US
Telephone Number	:	928-453-2225
Fax Number	:	928-453-4791

Provider Business Practice Location Address
First Line	:	2240 MCCULLOCH BLVD N
Second Line	:	STE C
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6904
Country	:	US
Telephone Number	:	928-453-2225
Fax Number	:	928-453-4791

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

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	09/12/2017

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