Provider Demographics
NPI:1528650751
Name:DAVIDSON, KEMOY (LAT, ATC, NREMT)
Entity type:Individual
Prefix:
First Name:KEMOY
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:LAT, ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E TRYON AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6154
Mailing Address - Country:US
Mailing Address - Phone:201-530-5064
Mailing Address - Fax:
Practice Address - Street 1:300 POMPTON RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2103
Practice Address - Country:US
Practice Address - Phone:973-720-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ641258146N00000X
NJ25MT002833002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic