Provider Demographics
NPI:1114563673
Name:DAVENPORT, MATTHEW STANCIL
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STANCIL
Last Name:DAVENPORT
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 1:2318 N NC HIGHWAY 58
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-9007
Mailing Address - Country:US
Mailing Address - Phone:252-813-0027
Mailing Address - Fax:252-459-2508
Practice Address - Street 1:2318 N NC HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-9007
Practice Address - Country:US
Practice Address - Phone:252-813-0027
Practice Address - Fax:252-459-2508
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home