1285720409 NPI number — ELIZABETH CANNON DAVIS PAC

Table of content: ELIZABETH CANNON DAVIS PAC (NPI 1285720409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285720409 NPI number — ELIZABETH CANNON DAVIS PAC

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CANNON
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285720409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 TREAT BLVD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94597-2168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-334-2098
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 TREAT BLVD STE 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94597-2168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-296-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2006

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: 363AM0700X , with the licence number:  PA54622 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 68-0360801 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".