Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT110419 | TX |
NPI | 1013465749 |
---|---|
Provider Name | Drue Davis |
First Address | Wichita Falls, TX 76308-3353 |
Second Address | Wichita Falls, TX 76301-4031 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2016 |
Last Update Date | 11/09/2016 |