Healthcare Provider Details

I. General information

NPI: 1689049256
Provider Name (Legal Business Name): TAYLOR COLTRIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6032 N TEAL WOOD CIR
PEORIA IL
61615-2231
US

IV. Provider business mailing address

6622 N QUEEN FRANCES LN
PEORIA IL
61615-7844
US

V. Phone/Fax

Practice location:
  • Phone: 309-258-7261
  • Fax:
Mailing address:
  • Phone: 309-258-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000026392
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: