Provider Demographics
NPI:1275886020
Name:DAVIS, RICHARD (LMP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-2611
Mailing Address - Country:US
Mailing Address - Phone:503-728-9604
Mailing Address - Fax:
Practice Address - Street 1:831 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2403
Practice Address - Country:US
Practice Address - Phone:360-636-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60284327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist