Provider Demographics
NPI:1790372886
Name:DAVIS, CRAIG
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6460 BEVERLY PIKE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-7459
Mailing Address - Country:US
Mailing Address - Phone:304-657-1692
Mailing Address - Fax:
Practice Address - Street 1:6460 BEVERLY PIKE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-7459
Practice Address - Country:US
Practice Address - Phone:304-657-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant