Healthcare Provider Details

I. General information

NPI: 1104314681
Provider Name (Legal Business Name): COLBY JAMES TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S FITNESS PL
EAGLE ID
83616-6828
US

IV. Provider business mailing address

1867 W DAINTY LN
MERIDIAN ID
83642-6868
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-6301
  • Fax:
Mailing address:
  • Phone: 208-991-8005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: