Provider Demographics
NPI:1679125819
Name:TAYLOR, SPENCER THOMAS
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:THOMAS
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 1:110 WILLARD CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4584
Mailing Address - Country:US
Mailing Address - Phone:229-886-3625
Mailing Address - Fax:
Practice Address - Street 1:110 WILLARD CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-4584
Practice Address - Country:US
Practice Address - Phone:229-886-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty