Provider Demographics
NPI:1336599588
Name:DAVIS, MARK RANDALL (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RANDALL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 6TH STREET CIR NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-5255
Mailing Address - Country:US
Mailing Address - Phone:828-327-5531
Mailing Address - Fax:
Practice Address - Street 1:1437 6TH STREET CIR NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-5255
Practice Address - Country:US
Practice Address - Phone:828-327-5531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer