Healthcare Provider Details

I. General information

NPI: 1639002736
Provider Name (Legal Business Name): SAMUEL TAGGARD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 MAIN ST
MANCHESTER CT
06040-5101
US

IV. Provider business mailing address

750 MAIN ST
MANCHESTER CT
06040-5101
US

V. Phone/Fax

Practice location:
  • Phone: 860-643-9500
  • Fax:
Mailing address:
  • Phone: 860-643-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14907
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: