Provider Demographics
NPI:1629146808
Name:TAYLOR MADE PEDIATRIC SERVICES INC
Entity Type:Organization
Organization Name:TAYLOR MADE PEDIATRIC SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-499-5489
Mailing Address - Street 1:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:TURNERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30580-0143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1688 BEN JONES RD
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-3106
Practice Address - Country:US
Practice Address - Phone:706-499-5489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003454225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA306019OtherWELLCARE NUMBER
GA10036312OtherAMERIGROUP NUMBER