Provider Demographics
NPI:1306213129
Name:DAVIS, OLIVER
Entity Type:Individual
Prefix:
First Name:OLIVER
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 1:4780 ARVILLE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5402
Mailing Address - Country:US
Mailing Address - Phone:702-830-9740
Mailing Address - Fax:
Practice Address - Street 1:65 REGENCY WAY
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3423
Practice Address - Country:US
Practice Address - Phone:775-636-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1780936435Medicaid