Provider Demographics
NPI:1609600816
Name:DAVIS, BOOKER IV
Entity type:Individual
Prefix:
First Name:BOOKER
Middle Name:
Last Name:DAVIS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W AGATITE AVE APT 1515
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6206
Mailing Address - Country:US
Mailing Address - Phone:312-898-4624
Mailing Address - Fax:
Practice Address - Street 1:811 W AGATITE AVE APT 1515
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6206
Practice Address - Country:US
Practice Address - Phone:312-898-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist