Provider Demographics
NPI:1336257435
Name:DAVIS, GREG C (DC)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:C
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 1:2240 MCCULLOCH BLVD N
Mailing Address - Street 2:STE C
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6904
Mailing Address - Country:US
Mailing Address - Phone:928-453-2225
Mailing Address - Fax:928-453-4791
Practice Address - Street 1:2240 MCCULLOCH BLVD N
Practice Address - Street 2:STE C
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6904
Practice Address - Country:US
Practice Address - Phone:928-453-2225
Practice Address - Fax:928-453-4791
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4259111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0243840OtherBLUE CROSS PROVIDER
AZ0243840OtherBLUE CROSS PROVIDER