Provider Demographics
NPI:1720218266
Name:TAYLOR, SAMUEL IRVING III
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:IRVING
Last Name:TAYLOR
Suffix:III
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 1:581 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1244
Mailing Address - Country:US
Mailing Address - Phone:415-410-4975
Mailing Address - Fax:
Practice Address - Street 1:581 63RD ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1244
Practice Address - Country:US
Practice Address - Phone:415-410-4975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children