MEDICARE: ALEXANDER JAMES 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	304105	MN

General Provider Information

NPI Number	:	1629748405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER JAMES DAVIS

Provider Business Mailing Address
First Line	:	1070 BUSH AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55106-3902
Country	:	US
Telephone Number	:	612-462-8416
Fax Number	:

Provider Business Practice Location Address
First Line	:	2912 N 2ND ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1606
Country	:	US
Telephone Number	:	612-462-8416
Fax Number	:

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

Provider Enumeration Date	:	09/14/2021
Last Update Date	:	09/14/2021

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