Provider Demographics
NPI:1336673938
Name:CLINKSCALES, TAYLOR JOSEPH
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JOSEPH
Last Name:CLINKSCALES
Suffix:
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 1:1420 BEARD ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6564
Mailing Address - Country:US
Mailing Address - Phone:810-689-6618
Mailing Address - Fax:
Practice Address - Street 1:1420 BEARD ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6564
Practice Address - Country:US
Practice Address - Phone:810-689-6618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010006225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist