MEDICARE: DAVIS & DAVIS NEW BEGINNINGS#1

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	320800000X	Mental Illness Community Based Residential Treatment Facility	MHL-060-855	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417097221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS & DAVIS NEW BEGINNINGS#1

Provider Business Mailing Address
First Line	:	624 N DAVIDSON ST
Second Line	:	C
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-3103
Country	:	US
Telephone Number	:	704-343-2462
Fax Number	:	704-398-3427

Provider Business Practice Location Address
First Line	:	1918 ERIE ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-4703
Country	:	US
Telephone Number	:	704-393-0497
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. LARRY EUGENE DAVIS
Credential	:
Telephone Number	:	704-343-2462

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/22/2020

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