1356780704 NPI number — MR. WILLIE DARE TAYLOR ABOC,NCLEC,MBOC

Table of content: MR. WILLIE DARE TAYLOR ABOC,NCLEC,MBOC (NPI 1356780704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356780704 NPI number — MR. WILLIE DARE TAYLOR ABOC,NCLEC,MBOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
WILLIE
Provider Middle Name:
DARE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ABOC,NCLEC,MBOC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356780704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
723 RIVER PARK VILLAGE BLVD
Provider Second Line Business Mailing Address:
MOBILE UNIT DISPENSARY
Provider Business Mailing Address City Name:
NORTHVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48167-2777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-378-7883
Provider Business Mailing Address Fax Number:
248-465-9985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
723 RIVER PARK VILLAGE BLVD
Provider Second Line Business Practice Location Address:
MOBILE UNIT DISPENSARY
Provider Business Practice Location Address City Name:
NORTHVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48167-2777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-378-7883
Provider Business Practice Location Address Fax Number:
248-465-9985
Provider Enumeration Date:
06/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  151016 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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