Provider Demographics
NPI:1174035927
Name:DAVIES, CHAD ARWYN
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:ARWYN
Last Name:DAVIES
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 1:717 W ELDREDGE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5620
Mailing Address - Country:US
Mailing Address - Phone:208-480-1250
Mailing Address - Fax:
Practice Address - Street 1:717 W ELDREDGE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5620
Practice Address - Country:US
Practice Address - Phone:208-480-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922463751Medicaid