Provider Demographics
NPI:1164781530
Name:DAVIS, ANDRE N
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:N
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 1:7075 W GOWAN RD
Mailing Address - Street 2:APT 1121 BLDG 25
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-7432
Mailing Address - Country:US
Mailing Address - Phone:702-764-2653
Mailing Address - Fax:
Practice Address - Street 1:7075 W GOWAN RD
Practice Address - Street 2:APT 1121 BLDG 25
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7432
Practice Address - Country:US
Practice Address - Phone:702-764-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner