Provider Demographics
NPI:1588793541
Name:DAVIS, STACEY D (DC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2671
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513
Mailing Address - Country:US
Mailing Address - Phone:706-632-2707
Mailing Address - Fax:706-632-2723
Practice Address - Street 1:351 E HIGHLAND ST
Practice Address - Street 2:SUITE A
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513
Practice Address - Country:US
Practice Address - Phone:706-632-2707
Practice Address - Fax:706-632-2723
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5406111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3939Medicare ID - Type Unspecified
35ZCGGRMedicare UPIN