Provider Demographics
NPI:1750822631
Name:TAYLOR, MARK K (CPO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAPLE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:49285
Mailing Address - Country:US
Mailing Address - Phone:734-678-2628
Mailing Address - Fax:
Practice Address - Street 1:110 MAPLE
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MI
Practice Address - Zip Code:49285
Practice Address - Country:US
Practice Address - Phone:734-678-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA15161744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI17OtherORTHOTICS/PROSTHETICS