Provider Demographics
NPI:1790131647
Name:DAVIS, DARNELL
Entity Type:Individual
Prefix:
First Name:DARNELL
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 1:1909 CHEKER SQ
Mailing Address - Street 2:
Mailing Address - City:EAST HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1442
Mailing Address - Country:US
Mailing Address - Phone:708-647-3331
Mailing Address - Fax:
Practice Address - Street 1:1909 CHEKER SQ
Practice Address - Street 2:
Practice Address - City:EAST HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1442
Practice Address - Country:US
Practice Address - Phone:708-647-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YAOYOOX324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility