Provider Demographics
NPI:1053972612
Name:DAVIS, IAN JOSIAH (DPT)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:JOSIAH
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S HAYMAKER DR
Mailing Address - Street 2:
Mailing Address - City:MILLIKEN
Mailing Address - State:CO
Mailing Address - Zip Code:80543-8324
Mailing Address - Country:US
Mailing Address - Phone:970-218-3630
Mailing Address - Fax:
Practice Address - Street 1:1159 MAIN ST UNIT A
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4711
Practice Address - Country:US
Practice Address - Phone:970-460-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0016445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist