Provider Demographics
NPI:1205058054
Name:DAVIS, MILES ALLAN (PT)
Entity type:Individual
Prefix:MR
First Name:MILES
Middle Name:ALLAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1552
Mailing Address - Country:US
Mailing Address - Phone:209-953-7577
Mailing Address - Fax:209-468-3516
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:209-953-7577
Practice Address - Fax:209-468-3516
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 33161167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician