Provider Demographics
NPI:1326012808
Name:DAVIS, ROGER F JR (DC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:F
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 E INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-9578
Mailing Address - Country:US
Mailing Address - Phone:863-699-0111
Mailing Address - Fax:863-699-1046
Practice Address - Street 1:155 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9578
Practice Address - Country:US
Practice Address - Phone:863-699-0111
Practice Address - Fax:863-699-1046
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007552111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280013600Medicaid
FLU90292Medicare UPIN
FLE7325Medicare ID - Type Unspecified