Provider Demographics
NPI:1376870733
Name:DAVIS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 KINGSBURG HWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-8004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1608 KINGSBURG HWY
Practice Address - Street 2:
Practice Address - City:JOHNSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29555-8004
Practice Address - Country:US
Practice Address - Phone:866-571-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant