Provider Demographics
NPI:1639779630
Name:ANDERSON, TAYLOR
Entity Type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:
Last Name:ANDERSON
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 1:3320 HONOLULU AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3389
Mailing Address - Country:US
Mailing Address - Phone:818-644-9491
Mailing Address - Fax:
Practice Address - Street 1:3320 HONOLULU AVE APT 11
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3389
Practice Address - Country:US
Practice Address - Phone:818-644-9491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer