Provider Demographics
NPI:1427652510
Name:DAVIS, RONDAL L
Entity type:Individual
Prefix:
First Name:RONDAL
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BROOKSEDGE DR E
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7339
Mailing Address - Country:US
Mailing Address - Phone:614-496-2726
Mailing Address - Fax:
Practice Address - Street 1:74 BROOKSEDGE DR E
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7339
Practice Address - Country:US
Practice Address - Phone:614-496-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2192443Medicaid