Healthcare Provider Details

I. General information

NPI: 1861646085
Provider Name (Legal Business Name): LISA VINCENT TAYLOR RD,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 PROSPECT STREET MILFORD REGIONAL MEDICAL CENTER
MILFORD MA
01757
US

IV. Provider business mailing address

3 BLACKSTONE ST
MENDON MA
01756-1304
US

V. Phone/Fax

Practice location:
  • Phone: 508-422-2393
  • Fax: 508-473-6251
Mailing address:
  • Phone: 508-478-5883
  • Fax: 508-473-6251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number956570
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: