1972021020 NPI number — INDIA SHAE DAVIDSON DPT

Table of content: INDIA SHAE DAVIDSON DPT (NPI 1972021020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972021020 NPI number — INDIA SHAE DAVIDSON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
INDIA
Provider Middle Name:
SHAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
METZ
Provider Other First Name:
INDIA
Provider Other Middle Name:
SHAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972021020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 DAVIS ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24060-7009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-381-9100
Provider Business Mailing Address Fax Number:
540-381-9102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 AKERS FARM RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHRISTIANSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24073-4865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-381-9100
Provider Business Practice Location Address Fax Number:
540-381-9102
Provider Enumeration Date:
09/08/2017

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: 225100000X , with the licence number:  2305209467 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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