Provider Demographics
NPI:1215539788
Name:DAVIS, MICHEAL
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
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 1:6047 TYVOLA GLEN CIR STE 113
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-6431
Mailing Address - Country:US
Mailing Address - Phone:803-431-5044
Mailing Address - Fax:
Practice Address - Street 1:6047 TYVOLA GLEN CIR STE 113
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-6431
Practice Address - Country:US
Practice Address - Phone:803-431-5044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-3729-01175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist