Provider Demographics
NPI:1467117770
Name:TAYLOR, MARTAVIOUS (DC)
Entity Type:Individual
Prefix:
First Name:MARTAVIOUS
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 HACKS CROSS RD STE 110
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-4032
Mailing Address - Country:US
Mailing Address - Phone:901-221-7173
Mailing Address - Fax:901-221-7934
Practice Address - Street 1:3615 S HOUSTON LEVEE RD STE 110
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-9173
Practice Address - Country:US
Practice Address - Phone:901-221-7173
Practice Address - Fax:901-221-7934
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3510111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor