Provider Demographics
NPI:1790415495
Name:DAVIS, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PALMETTO STATE
Other - Middle Name:
Other - Last Name:MEDICAL TRANSPORT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2002 E LEE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-3544
Mailing Address - Country:US
Mailing Address - Phone:864-516-4340
Mailing Address - Fax:
Practice Address - Street 1:2002 E LEE RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-3544
Practice Address - Country:US
Practice Address - Phone:864-516-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)