MEDICARE: MR. JOHN L DAVIS MS, ATC

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	225500000X	Respiratory/Developmental/Rehabilitative Specialist/Technologist	25MT00010700	NJ

General Provider Information

NPI Number	:	1689647208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN L DAVIS MS, ATC

Provider Business Mailing Address
First Line	:	22 HILTON ST
Second Line	:
City	:	PEQUANNOCK
State	:	NJ
Zip	:	07440-1311
Country	:	US
Telephone Number	:	973-633-8010
Fax Number	:

Provider Business Practice Location Address
First Line	:	MONTCLAIR STATE UNIVERSITY
Second Line	:	1 NORMAL AVE.
City	:	MONTCLAIR
State	:	NJ
Zip	:	07043-1624
Country	:	US
Telephone Number	:	973-655-5250
Fax Number	:	973-655-5436

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

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	07/08/2007

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