Provider Demographics
NPI:1588073175
Name:DAVIS, CHARLES R JR (HHA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 E CARPENTER DR
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-2529
Mailing Address - Country:US
Mailing Address - Phone:937-238-1347
Mailing Address - Fax:
Practice Address - Street 1:436 E CARPENTER DR
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45344-2529
Practice Address - Country:US
Practice Address - Phone:937-238-1347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH107010732999Medicaid