Provider Demographics
NPI:1124225354
Name:DAVIS CHIROPRACTIC, P.A.
Entity type:Organization
Organization Name:DAVIS CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-386-7920
Mailing Address - Street 1:689 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-3254
Mailing Address - Country:US
Mailing Address - Phone:612-386-7920
Mailing Address - Fax:
Practice Address - Street 1:330 PRAIRIE CENTER DRIVE
Practice Address - Street 2:210
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344
Practice Address - Country:US
Practice Address - Phone:612-501-1036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2642111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty