Provider Demographics
NPI:1275956427
Name:DAVIS, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15505 CIVIC DR
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2357
Mailing Address - Country:US
Mailing Address - Phone:760-243-8247
Mailing Address - Fax:760-243-8158
Practice Address - Street 1:15505 CIVIC DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2357
Practice Address - Country:US
Practice Address - Phone:760-243-8247
Practice Address - Fax:760-243-8158
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator