Provider Demographics
NPI:1790244317
Name:TAX, MICHAEL KENNETH (LPN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENNETH
Last Name:TAX
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5413
Mailing Address - Country:US
Mailing Address - Phone:631-295-7701
Mailing Address - Fax:
Practice Address - Street 1:125 OAKLAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2130
Practice Address - Country:US
Practice Address - Phone:631-686-1414
Practice Address - Fax:631-686-1462
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262016-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse