Provider Demographics
NPI:1689961732
Name:MILDENHALL, TAYLOR J (MS PT)
Entity Type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:J
Last Name:MILDENHALL
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Gender:M
Credentials:MS PT
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Mailing Address - Street 1:1741 HOG MOUNTAIN RD
Mailing Address - Street 2:BLDG 100
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-1947
Mailing Address - Country:US
Mailing Address - Phone:706-769-6261
Mailing Address - Fax:706-769-6316
Practice Address - Street 1:1741 HOG MOUNTAIN RD
Practice Address - Street 2:BLDG 100
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-1947
Practice Address - Country:US
Practice Address - Phone:706-769-6261
Practice Address - Fax:706-769-6316
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
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Provider Licenses
StateLicense IDTaxonomies
GAPT010346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6734Medicare PIN