Basic Information
| Provider Information | |||||||||
| NPI: | 1891370953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | BT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12862 COLONNADE DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917399347 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 CORPORATE CENTER DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917682627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096180974 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2021 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.