Healthcare Provider Details

I. General information

NPI: 1811739089
Provider Name (Legal Business Name): TAYLOR BONTRAGER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7975 LAKE UNDERHILL RD STE 200
ORLANDO FL
32822-8204
US

IV. Provider business mailing address

123 S VINE ST
ELKHART IN
46514-2509
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6830
  • Fax:
Mailing address:
  • Phone: 574-575-2174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: