Provider Demographics
NPI:1265621361
Name:HAROLD E DAVIS & TERRY ALAN TRUST ETAL
Entity type:Organization
Organization Name:HAROLD E DAVIS & TERRY ALAN TRUST ETAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASST.
Authorized Official - Prefix:MS
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-636-0600
Mailing Address - Street 1:4663 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2540
Mailing Address - Country:US
Mailing Address - Phone:708-636-0600
Mailing Address - Fax:708-636-0606
Practice Address - Street 1:4663 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2540
Practice Address - Country:US
Practice Address - Phone:708-636-0600
Practice Address - Fax:708-636-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046004083305R00000X
IL046007173305R00000X
IL046009277305R00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL506370Medicare PIN
IL0522810001Medicare NSC