Provider Demographics
NPI:1598310351
Name:DAVIS, LANCE
Entity Type:Individual
Prefix:
First Name:LANCE
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 1:3 SAINT JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 THORNTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4416
Practice Address - Country:US
Practice Address - Phone:646-801-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No174H00000XOther Service ProvidersHealth Educator