Provider Demographics
NPI:1508153040
Name:DAVIS, III, ERVIN (ASSOCIATE DEGREE)
Entity Type:Individual
Prefix:
First Name:ERVIN
Middle Name:
Last Name:DAVIS, III
Suffix:
Gender:M
Credentials:ASSOCIATE DEGREE
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ASSOCIATE DEGREE
Mailing Address - Street 1:316 STALLINGS RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-3808
Mailing Address - Country:US
Mailing Address - Phone:919-605-9981
Mailing Address - Fax:
Practice Address - Street 1:515 YADKIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-3578
Practice Address - Country:US
Practice Address - Phone:919-605-9981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker