Provider Demographics
NPI:1952447054
Name:DAVIS, RICHARD HOWARD (LPTA, CMT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:HOWARD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPTA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103H PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-9434
Mailing Address - Country:US
Mailing Address - Phone:276-935-5525
Mailing Address - Fax:
Practice Address - Street 1:1103H PLAZA DR
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-9434
Practice Address - Country:US
Practice Address - Phone:276-935-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001366261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000838Medicaid
WV3810000838Medicaid