Provider Demographics
NPI:1326058264
Name:DAVIS, DAVID (PT, OCS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 BLUEWATER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3887
Mailing Address - Country:US
Mailing Address - Phone:850-897-3334
Mailing Address - Fax:850-897-7855
Practice Address - Street 1:1950 BLUEWATER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3887
Practice Address - Country:US
Practice Address - Phone:850-897-3334
Practice Address - Fax:850-897-7855
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY906WOtherGROUP
FLY906WOtherGROUP