Provider Demographics
NPI:1649362146
Name:DAVIS, LARRY T (DC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:T
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 1:3012 CENTRE OAK WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-590-1065
Mailing Address - Fax:
Practice Address - Street 1:3012 CENTRE OAK WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-590-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6244189OtherCIGNA
TN0038807OtherBCBS
T74580Medicare UPIN
TN6244189OtherCIGNA