Provider Demographics
NPI:1245410281
Name:CLINT T TAYLOR OD LLC
Entity Type:Organization
Organization Name:CLINT T TAYLOR OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:T
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-382-4683
Mailing Address - Street 1:304 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1604
Mailing Address - Country:US
Mailing Address - Phone:618-382-4683
Mailing Address - Fax:618-382-4684
Practice Address - Street 1:304 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1604
Practice Address - Country:US
Practice Address - Phone:618-382-4683
Practice Address - Fax:618-382-4684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
212125Medicare PIN
5516970001Medicare NSC
K20038Medicare UPIN