Provider Demographics
NPI:1023143237
Name:DAVIS, DARRELL WADE (DC)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:WADE
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 1:1155 S. YELLOWSTONE
Mailing Address - Street 2:STE. F
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-238-0002
Mailing Address - Fax:
Practice Address - Street 1:1155 YELLOWSTONE AVE
Practice Address - Street 2:STE. F
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4369
Practice Address - Country:US
Practice Address - Phone:208-238-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU44140Medicare UPIN