Provider Demographics
NPI:1457481269
Name:DAVIS, BRENDA (ORT)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 E ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5580
Mailing Address - Country:US
Mailing Address - Phone:209-572-3224
Mailing Address - Fax:209-572-4528
Practice Address - Street 1:609 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5580
Practice Address - Country:US
Practice Address - Phone:209-572-3224
Practice Address - Fax:209-572-4528
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA04-0222246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA04-0222OtherCERT ORTHOPAEDIC TECH