Provider Demographics
NPI:1083096390
Name:DAVIS, PATRICK LEON
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:LEON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 S MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4740
Mailing Address - Country:US
Mailing Address - Phone:419-352-4624
Mailing Address - Fax:419-354-1774
Practice Address - Street 1:1084 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4740
Practice Address - Country:US
Practice Address - Phone:419-352-4624
Practice Address - Fax:419-354-1774
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141073171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator