Provider Demographics
NPI:1699875419
Name:DAVIS, KEITH G (DC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:G
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 FRONT ST
Mailing Address - Street 2:PO BOX 518
Mailing Address - City:CASSELTON
Mailing Address - State:ND
Mailing Address - Zip Code:58012-3302
Mailing Address - Country:US
Mailing Address - Phone:701-347-4006
Mailing Address - Fax:701-347-4247
Practice Address - Street 1:722 FRONT STREET
Practice Address - Street 2:
Practice Address - City:CASSELTON
Practice Address - State:ND
Practice Address - Zip Code:58012-3302
Practice Address - Country:US
Practice Address - Phone:701-347-4006
Practice Address - Fax:701-347-4247
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND413111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13919Medicaid
4304Medicare PIN