Provider Demographics
NPI:1255970430
Name:DAVIS, LORA JEAN (ARDMS, AFC)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ARDMS, AFC
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 2977
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-2977
Mailing Address - Country:US
Mailing Address - Phone:313-590-9139
Mailing Address - Fax:313-278-5243
Practice Address - Street 1:3307 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4159
Practice Address - Country:US
Practice Address - Phone:313-278-2805
Practice Address - Fax:313-278-5243
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI320700000X, 320800000X, 320900000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities