Provider Demographics
NPI:1356780704
Name:TAYLOR, WILLIE DARE (ABOC,NCLEC,MBOC)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:DARE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:ABOC,NCLEC,MBOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 RIVER PARK VILLAGE BLVD
Mailing Address - Street 2:MOBILE UNIT DISPENSARY
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2777
Mailing Address - Country:US
Mailing Address - Phone:313-378-7883
Mailing Address - Fax:248-465-9985
Practice Address - Street 1:723 RIVER PARK VILLAGE BLVD
Practice Address - Street 2:MOBILE UNIT DISPENSARY
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2777
Practice Address - Country:US
Practice Address - Phone:313-378-7883
Practice Address - Fax:248-465-9985
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI151016156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician