Provider Demographics
NPI:1881450849
Name:DAVENPORT, GREG
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:DAVENPORT
Suffix:
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 1:4119 MARBLE DR
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5387
Mailing Address - Country:US
Mailing Address - Phone:760-274-4105
Mailing Address - Fax:
Practice Address - Street 1:4119 MARBLE DR
Practice Address - Street 2:
Practice Address - City:MEAD
Practice Address - State:CO
Practice Address - Zip Code:80504-5387
Practice Address - Country:US
Practice Address - Phone:760-274-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0025357225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist