Provider Demographics
NPI:1114386158
Name:TAYLOR, JOHNNY JR
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:TAYLOR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9821 SUMMERWOOD CIR
Mailing Address - Street 2:2405
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5709
Mailing Address - Country:US
Mailing Address - Phone:661-390-3553
Mailing Address - Fax:
Practice Address - Street 1:9821 SUMMERWOOD CIR
Practice Address - Street 2:2405
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:661-390-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other