Provider Demographics
NPI:1568977296
Name:DAVIS, DAREN RICHARD
Entity Type:Individual
Prefix:PROF
First Name:DAREN
Middle Name:RICHARD
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 1:107 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4223
Mailing Address - Country:US
Mailing Address - Phone:208-522-1604
Mailing Address - Fax:208-549-7860
Practice Address - Street 1:107 W 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4223
Practice Address - Country:US
Practice Address - Phone:208-522-1604
Practice Address - Fax:208-549-7860
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY177237700000X
IDHA2037237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist