Healthcare Provider Details

I. General information

NPI: 1104070549
Provider Name (Legal Business Name): KEITH CHANDLER TAYLOR ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 MAGNOLIA WAY
AUGUSTA GA
30909
US

IV. Provider business mailing address

3624 J DEWEY GRAY CIR SUITE 308
AUGUSTA GA
30909-6584
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-7529
  • Fax:
Mailing address:
  • Phone: 706-210-7529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000386
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: