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NPI Code Detail

MEDICARE: ELIZABETH ANNE DAVIS ATC, LAT

MEDICARE:   ELIZABETH ANNE DAVIS  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
12081S0010XSports Medicine (Physical Medicine & Rehabilitation) Physician2000007791OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12000007791OTHERNATABOC
2ATR-LAT-LIC-867OTHERMTMONTANA ATHLETIC TRAINING LICENSURE

General Provider Information

NPI Number : 1720471329
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIZABETH ANNE DAVIS ATC, LAT
Provider Business Mailing Address
First Line : 945 VENICE BEACH WAY
Second Line : UNIT 4
City : BILLINGS
State : MT
Zip : 59106-2490
Country : US
Telephone Number : 406-589-6163
Fax Number :
Provider Business Practice Location Address
First Line : 1500 UNIVERSITY DR
Second Line : ATHLETIC DEPARTMENT
City : BILLINGS
State : MT
Zip : 59101-0245
Country : US
Telephone Number : 406-657-2375
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/06/2015
Last Update Date : 03/06/2015

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