Provider Demographics
NPI:1770576852
Name:TAYLOR, BENJAMIN BRANDT (RPT)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:BRANDT
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-0623
Mailing Address - Country:US
Mailing Address - Phone:620-431-0887
Mailing Address - Fax:620-431-0816
Practice Address - Street 1:305 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-2350
Practice Address - Country:US
Practice Address - Phone:620-431-0887
Practice Address - Fax:620-431-0887
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1102895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
381860OtherFIRSTGUARD
KS1102895OtherKS STATE LICENSE
KS140190TAMedicare ID - Type Unspecified
KS1102895OtherKS STATE LICENSE