Provider Demographics
NPI:1972227908
Name:MICKEL, TAYLOR (LDO)
Entity Type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:
Last Name:MICKEL
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 SEA ISLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1535
Mailing Address - Country:US
Mailing Address - Phone:843-489-3213
Mailing Address - Fax:
Practice Address - Street 1:265 SEA ISLAND PKWY
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1535
Practice Address - Country:US
Practice Address - Phone:843-489-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1229156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician