Provider Demographics
NPI:1073940607
Name:DAVIS, EVITA
Entity Type:Individual
Prefix:MRS
First Name:EVITA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6696 BOOMTOWN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122
Mailing Address - Country:US
Mailing Address - Phone:323-351-6677
Mailing Address - Fax:
Practice Address - Street 1:6696 BOOM TOWN DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-8632
Practice Address - Country:US
Practice Address - Phone:323-351-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner