MEDICARE: MIA DAVIS

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		TX

General Provider Information

NPI Number	:	1427591494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA DAVIS

Provider Business Mailing Address
First Line	:	5903 GRACE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-3424
Country	:	US
Telephone Number	:	713-397-0208
Fax Number	:

Provider Business Practice Location Address
First Line	:	5903 GRACE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-3424
Country	:	US
Telephone Number	:	713-307-0208
Fax Number	:

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

Provider Enumeration Date	:	11/23/2016
Last Update Date	:	11/23/2016

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Directions to “ MIA DAVIS ” Practice Location

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