Provider Demographics
NPI:1003998949
Name:TAYLOR, KEVIN KEITH (MS, ATC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:KEITH
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8157 W GALILEO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-7899
Mailing Address - Country:US
Mailing Address - Phone:208-440-2488
Mailing Address - Fax:
Practice Address - Street 1:6485 W INTERCHANGE
Practice Address - Street 2:SUITE 103
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-440-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-2122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer