Provider Demographics
NPI:1366702060
Name:DAVIS, CLARA M
Entity type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 W DUBAIL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613-1216
Mailing Address - Country:US
Mailing Address - Phone:574-233-2287
Mailing Address - Fax:
Practice Address - Street 1:1719 W DUBAIL ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613-1216
Practice Address - Country:US
Practice Address - Phone:574-233-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle