MEDICARE: MR. LONNIE RAY DAVIS, JR MSS, ATC, LAT

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	2255A2300X	Athletic Trainer	0091	NC

General Provider Information

NPI Number	:	1588776637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LONNIE RAY DAVIS, JR MSS, ATC, LAT

Provider Business Mailing Address
First Line	:	740 E FRANKLIN ST
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27514-3823
Country	:	US
Telephone Number	:	919-928-9099
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 W LAKE RD
Second Line	:	WEST LAKE MIDDLE SCHOOL
City	:	APEX
State	:	NC
Zip	:	27539-7657
Country	:	US
Telephone Number	:	919-662-2918
Fax Number	:	919-662-2906

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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