Provider Demographics
NPI:1598813131
Name:DAVIS, LARRY (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 E SHEA BLVD STE 205
Mailing Address - Street 2:STE 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3209
Mailing Address - Country:US
Mailing Address - Phone:602-206-3701
Mailing Address - Fax:480-404-7140
Practice Address - Street 1:3101 E SHEA BLVD STE 205
Practice Address - Street 2:STE 205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3209
Practice Address - Country:US
Practice Address - Phone:602-206-3701
Practice Address - Fax:480-404-7140
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7667111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ123226Medicare PIN