1770371866 NPI number — ENDIRA MADRE DAVIS CED-L, CED-PIC

Table of content: ENDIRA MADRE DAVIS CED-L, CED-PIC (NPI 1770371866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770371866 NPI number — ENDIRA MADRE DAVIS CED-L, CED-PIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
ENDIRA
Provider Middle Name:
MADRE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CED-L, CED-PIC
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:
1770371866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1638 ALPINE AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49504-2802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-515-7769
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1638 ALPINE AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49504-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-515-7769
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2025

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: 374J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com