Healthcare Provider Details

I. General information

NPI: 1013979046
Provider Name (Legal Business Name): ERIC ANTHONY TAYLOR ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 W MCMILLAN RD
BOISE ID
83713-0529
US

IV. Provider business mailing address

12889 W GOLDENBROOK CT
BOISE ID
83713-1444
US

V. Phone/Fax

Practice location:
  • Phone: 208-340-0753
  • Fax:
Mailing address:
  • Phone: 208-350-9626
  • Fax: 208-939-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-071
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: