Healthcare Provider Details

I. General information

NPI: 1124040241
Provider Name (Legal Business Name): TA TAYLOR ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3046 DEL PRADO BLVD S SUITE 1A
CAPE CORAL FL
33904-7221
US

IV. Provider business mailing address

3046 DEL PRADO BLVD S SUITE 1A
CAPE CORAL FL
33904-7221
US

V. Phone/Fax

Practice location:
  • Phone: 239-540-9918
  • Fax: 239-540-9192
Mailing address:
  • Phone: 239-540-9918
  • Fax: 239-540-9192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME92674
License Number StateFL

VIII. Authorized Official

Name: DR. TERESE ANN TAYLOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 239-540-9918