MEDICARE: DAVIS CLINIC MANAGEMENT INC

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1841628427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS CLINIC MANAGEMENT INC

Provider Business Mailing Address
First Line	:	21 SCHOOL ST
Second Line	:	SUITE 1
City	:	QUINCY
State	:	MA
Zip	:	02169-6640
Country	:	US
Telephone Number	:	860-839-4508
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 SCHOOL ST
Second Line	:	SUITE 1
City	:	QUINCY
State	:	MA
Zip	:	02169-6640
Country	:	US
Telephone Number	:	860-839-4508
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAVID TKHILAISHVILI
Credential	:
Telephone Number	:	860-839-4508

Provider Enumeration Date	:	10/17/2013
Last Update Date	:	10/17/2013

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