Provider Demographics
NPI:1396174751
Name:DAVIS, JOHN SR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DAVIS
Suffix:SR
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 1:339 KINGS RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6327
Mailing Address - Country:US
Mailing Address - Phone:618-624-2969
Mailing Address - Fax:
Practice Address - Street 1:339 KINGS RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-6327
Practice Address - Country:US
Practice Address - Phone:618-624-2969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004009573163W00000X
IL041341411163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse