Provider Demographics
NPI:1104094127
Name:KRISTI K DAVIS OD INC
Entity type:Organization
Organization Name:KRISTI K DAVIS OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-222-7271
Mailing Address - Street 1:2515 PARK MARINA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2831
Mailing Address - Country:US
Mailing Address - Phone:530-222-7271
Mailing Address - Fax:530-222-5282
Practice Address - Street 1:2515 PARK MARINA DR
Practice Address - Street 2:SUITE 201
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2831
Practice Address - Country:US
Practice Address - Phone:530-222-7271
Practice Address - Fax:530-222-5282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11942T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0119420Medicaid
CA4927390001Medicare NSC
U91434Medicare UPIN
CASD0119421Medicare PIN