Provider Demographics
NPI:1356016307
Name:TIMES, TAIDRA DENEAN
Entity Type:Individual
Prefix:
First Name:TAIDRA
Middle Name:DENEAN
Last Name:TIMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:GA
Mailing Address - Zip Code:31803-0098
Mailing Address - Country:US
Mailing Address - Phone:229-331-9033
Mailing Address - Fax:
Practice Address - Street 1:205 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:GA
Practice Address - Zip Code:31803-1909
Practice Address - Country:US
Practice Address - Phone:229-331-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility