1609309111 NPI number — RENDLE TAYLOR DPT

Table of content: RENDLE TAYLOR DPT (NPI 1609309111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609309111 NPI number — RENDLE TAYLOR DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
RENDLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1609309111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 N ARLINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89503-4723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-786-3040
Provider Business Mailing Address Fax Number:
775-786-1887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5070 ION DR STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89436-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-786-3040
Provider Business Practice Location Address Fax Number:
775-348-3054
Provider Enumeration Date:
04/11/2017

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: 225100000X , with the licence number:  3509 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14377880 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 250000366 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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