Provider Demographics
NPI:1669074126
Name:DAVIS, DILLON BARTHOLOMEW (LAT,ATC)
Entity type:Individual
Prefix:
First Name:DILLON
Middle Name:BARTHOLOMEW
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 E VALLEY WATER MILL RD APT 2902
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4923
Mailing Address - Country:US
Mailing Address - Phone:417-217-2380
Mailing Address - Fax:
Practice Address - Street 1:3126 E VALLEY WATER MILL RD APT 2902
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4923
Practice Address - Country:US
Practice Address - Phone:417-217-2380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200269072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer