Provider Demographics
NPI:1396083390
Name:DAVIS, LARRY E JR
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:E
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 GLENWOOD AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-1043
Mailing Address - Country:US
Mailing Address - Phone:330-318-0392
Mailing Address - Fax:
Practice Address - Street 1:4011 GLENWOOD AVE
Practice Address - Street 2:APT 1
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-1043
Practice Address - Country:US
Practice Address - Phone:330-318-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH142811164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse