Provider Demographics
NPI:1740320878
Name:DAVIS, DETRIS DENISE
Entity type:Individual
Prefix:MS
First Name:DETRIS
Middle Name:DENISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-4303
Mailing Address - Country:US
Mailing Address - Phone:213-639-2678
Mailing Address - Fax:
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-639-2678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner