Provider Demographics
NPI:1659604189
Name:DR FRED DAVIS AND ASSOCIATES
Entity Type:Organization
Organization Name:DR FRED DAVIS AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-449-9000
Mailing Address - Street 1:615 S CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-5107
Mailing Address - Country:US
Mailing Address - Phone:615-449-9000
Mailing Address - Fax:615-444-5940
Practice Address - Street 1:615 S CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-5107
Practice Address - Country:US
Practice Address - Phone:615-449-9000
Practice Address - Fax:615-444-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1177152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN35966341OtherMEDICARE PTAN