Provider Demographics
NPI:1063969848
Name:DAVIS, JOHN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:117 NE 46TH LN UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-8115
Mailing Address - Country:US
Mailing Address - Phone:949-374-1691
Mailing Address - Fax:
Practice Address - Street 1:1800 S 4TH ST
Practice Address - Street 2:JACOBSON BUILDING
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50011-1142
Practice Address - Country:US
Practice Address - Phone:515-294-6315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0798402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer