Provider Demographics
NPI:1922776046
Name:LICCAR, TAYLOR (DC)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:
Last Name:LICCAR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1445
Mailing Address - Country:US
Mailing Address - Phone:309-824-8065
Mailing Address - Fax:
Practice Address - Street 1:1100 BEECH ST STE 13B
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1499
Practice Address - Country:US
Practice Address - Phone:309-323-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012949111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor