Provider Demographics
NPI:1629739511
Name:TAYLOR, VONTRAY LEWIS
Entity Type:Individual
Prefix:
First Name:VONTRAY
Middle Name:LEWIS
Last Name:TAYLOR
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 1:2736 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-3015
Mailing Address - Country:US
Mailing Address - Phone:951-775-0584
Mailing Address - Fax:
Practice Address - Street 1:2736 SPRING ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-3015
Practice Address - Country:US
Practice Address - Phone:951-775-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist