1356863294 NPI number — DAVID TAYLOR PAYNE IV LAT, ATC

Table of content: DAVID TAYLOR PAYNE IV LAT, ATC (NPI 1356863294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356863294 NPI number — DAVID TAYLOR PAYNE IV LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
DAVID
Provider Middle Name:
TAYLOR
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
Provider Credential Text:
LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAYNE
Provider Other First Name:
DAVID
Provider Other Middle Name:
TAYLOR
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
IV
Provider Other Credential Text:
LAT, ATC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356863294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 BOB WHITE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KATHLEEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31047-2513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-957-2535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 BOB WHITE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KATHLEEN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-957-2535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2017

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: 2255A2300X , with the licence number:  AT003089 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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