1083018501 NPI number — LIESA A DAVIS NP-C

Table of content: LIESA A DAVIS NP-C (NPI 1083018501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083018501 NPI number — LIESA A DAVIS NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
LIESA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRAND
Provider Other First Name:
LIESA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083018501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4640 W ALEXIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43623-1182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-474-9324
Provider Business Mailing Address Fax Number:
552-870-1608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4640 W ALEXIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43623-1182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-474-9324
Provider Business Practice Location Address Fax Number:
855-287-0160
Provider Enumeration Date:
10/13/2014

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: 363LF0000X , with the licence number:  COA.15925-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0112089 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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