Healthcare Provider Details

I. General information

NPI: 1245410281
Provider Name (Legal Business Name): CLINT T TAYLOR OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S CHURCH ST
CARMI IL
62821-1604
US

IV. Provider business mailing address

304 S CHURCH ST
CARMI IL
62821-1604
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-4683
  • Fax: 618-382-4684
Mailing address:
  • Phone: 618-382-4683
  • Fax: 618-382-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CLINT T. TAYLOR
Title or Position: OWNER
Credential: OD
Phone: 618-382-4683