Provider Demographics
NPI:1053512129
Name:DAVIS, GEORGE GRANT (PT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:GRANT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 WAIANUENUE AVE
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1202
Mailing Address - Country:US
Mailing Address - Phone:808-961-6644
Mailing Address - Fax:808-934-2359
Practice Address - Street 1:1333 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-1202
Practice Address - Country:US
Practice Address - Phone:808-961-6644
Practice Address - Fax:808-934-2359
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist