Provider Demographics
NPI:1194457358
Name:TAYLOR, DEHAVEN PRESTON (LDO)
Entity Type:Individual
Prefix:
First Name:DEHAVEN
Middle Name:PRESTON
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 N HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3132
Mailing Address - Country:US
Mailing Address - Phone:843-899-5872
Mailing Address - Fax:843-899-5875
Practice Address - Street 1:511 N HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3132
Practice Address - Country:US
Practice Address - Phone:843-899-5872
Practice Address - Fax:843-899-5875
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1207156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician