1225320245 NPI number — PHYLLIS DAVIS

Table of content: PHYLLIS DAVIS (NPI 1225320245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225320245 NPI number — PHYLLIS DAVIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
PHYLLIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225320245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 772
Provider Second Line Business Mailing Address:
MINUTECLINIC CREDENTIALING
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895-0784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-389-2727
Provider Business Mailing Address Fax Number:
401-652-9787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
183 US HIGHWAY 206 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07930-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-389-2727
Provider Business Practice Location Address Fax Number:
401-652-9787
Provider Enumeration Date:
05/10/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  SP023559 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)