Provider Demographics
NPI:1174719033
Name:DAVIS, CHARLES HENRY
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HENRY
Last Name:DAVIS
Suffix:
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 1:4859 SHED RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOSSIER
Mailing Address - State:LA
Mailing Address - Zip Code:71111-4859
Mailing Address - Country:US
Mailing Address - Phone:318-746-5000
Mailing Address - Fax:318-746-4000
Practice Address - Street 1:4859 SHED RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-746-5000
Practice Address - Fax:318-746-4000
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA222Z00000X, 224P00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist