Healthcare Provider Details

I. General information

NPI: 1154040244
Provider Name (Legal Business Name): TAYLOR VIXIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 JOHNSTONVILLE RD
SUSANVILLE CA
96130-8739
US

IV. Provider business mailing address

3020 JOHNSTONVILLE RD
SUSANVILLE CA
96130-8739
US

V. Phone/Fax

Practice location:
  • Phone: 530-257-2395
  • Fax: 530-257-6914
Mailing address:
  • Phone: 530-257-2395
  • Fax: 530-257-6914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number107843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: