1780808196 NPI number — JIM GLENN DAVIS

Table of content: JIM GLENN DAVIS (NPI 1780808196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780808196 NPI number — JIM GLENN DAVIS

Organization/Personal Information

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

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:
1780808196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
502 GREENING STREET
Provider Second Line Business Mailing Address:
SUITE 3C
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-837-4065
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 GREENING ST
Provider Second Line Business Practice Location Address:
SUITE 3C
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71701-3491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-837-4065
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007

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: 174400000X , with the licence number:  C00332 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: C000332 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 135850002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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