Provider Demographics
NPI:1164103446
Name:DR. ROGER DAVIS, LLC
Entity Type:Organization
Organization Name:DR. ROGER DAVIS, LLC
Other - Org Name:D
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-776-0578
Mailing Address - Street 1:2557 SHERMAN OAK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34289-2390
Mailing Address - Country:US
Mailing Address - Phone:573-776-0578
Mailing Address - Fax:
Practice Address - Street 1:2557 SHERMAN OAK DR
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-2390
Practice Address - Country:US
Practice Address - Phone:573-776-0578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty