1174700397 NPI number — TAYLOR CHIROPRACTIC CORP

Table of content: (NPI 1174700397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174700397 NPI number — TAYLOR CHIROPRACTIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAYLOR CHIROPRACTIC CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1174700397
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
682 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHIPLEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32428-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-377-1246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
682 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHIPLEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32428-1430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-377-1246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT/CHIROPRACTOR
Authorized Official Telephone Number:
904-377-1246

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH8725 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000749400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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