Provider Demographics
NPI: | 1497015499 |
---|---|
Name: | DAVENPORT, PETER MILO |
Entity Type: | Individual |
Prefix: | MR |
First Name: | PETER |
Middle Name: | MILO |
Last Name: | DAVENPORT |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | DBA ANGELS |
Other - Middle Name: | HELPING |
Other - Last Name: | HANDS |
Other - Suffix: | |
Other - Last Name Type: | Professional Name |
Other - Credentials: | |
Mailing Address - Street 1: | 116 N 2ND ST |
Mailing Address - Street 2: | |
Mailing Address - City: | CLARKSVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37040-3478 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 931-220-7449 |
Mailing Address - Fax: | 270-466-5075 |
Practice Address - Street 1: | 116 N 2ND ST |
Practice Address - Street 2: | |
Practice Address - City: | CLARKSVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37040-3478 |
Practice Address - Country: | US |
Practice Address - Phone: | 931-220-7449 |
Practice Address - Fax: | 270-466-5075 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2012-05-23 |
Last Update Date: | 2012-06-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | L0000000009366 | 385H00000X, 374U00000X, 376J00000X |
KY | D99-281-661 | 172A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 376J00000X | Nursing Service Related Providers | Homemaker | |
No | 385H00000X | Respite Care Facility | Respite Care | |
No | 374U00000X | Nursing Service Related Providers | Home Health Aide | |
No | 172A00000X | Other Service Providers | Driver |