Provider Demographics
NPI:1760020630
Name:TAYLOR, BRANDON
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
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 1:187 SHAKER HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7583
Mailing Address - Country:US
Mailing Address - Phone:678-687-8489
Mailing Address - Fax:
Practice Address - Street 1:187 SHAKER HOLLOW DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7583
Practice Address - Country:US
Practice Address - Phone:678-687-8489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility