MEDICARE: MIRANDA PAIGE DAVIDSON

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	224Z00000X	Occupational Therapy Assistant	0131001518	VA

General Provider Information

NPI Number	:	1588283618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA PAIGE DAVIDSON

Provider Business Mailing Address
First Line	:	514 N MAIN ST
Second Line	:
City	:	RURAL RETREAT
State	:	VA
Zip	:	24368-3123
Country	:	US
Telephone Number	:	276-686-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	514 N MAIN ST
Second Line	:
City	:	RURAL RETREAT
State	:	VA
Zip	:	24368-3123
Country	:	US
Telephone Number	:	276-686-7000
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	04/09/2020

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