Provider Demographics
NPI:1356306088
Name:DAVIS, DARYL ELLIS (DC)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:ELLIS
Last Name:DAVIS
Suffix:
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 1:202 S MARION ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302
Mailing Address - Country:US
Mailing Address - Phone:708-386-2090
Mailing Address - Fax:708-386-2092
Practice Address - Street 1:202 S MARION ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:708-386-2090
Practice Address - Fax:708-386-2092
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007677Medicaid
IL038007677Medicaid
U57654Medicare UPIN