Provider Demographics
NPI:1780490961
Name:TAYLOR, KENEVIL
Entity type:Individual
Prefix:
First Name:KENEVIL
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-9168
Mailing Address - Country:US
Mailing Address - Phone:330-312-0319
Mailing Address - Fax:
Practice Address - Street 1:940 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:CANAL FULTON
Practice Address - State:OH
Practice Address - Zip Code:44614-9168
Practice Address - Country:US
Practice Address - Phone:330-312-0319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRR362794172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver