Provider Demographics
NPI:1063628931
Name:DAVIS, MARCUS J (ATC, LAT)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 WRIGHT CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-7362
Mailing Address - Country:US
Mailing Address - Phone:317-736-0722
Mailing Address - Fax:
Practice Address - Street 1:625 GRIZZLY CUB DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-1362
Practice Address - Country:US
Practice Address - Phone:317-847-5817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000969A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer