Healthcare Provider Details

I. General information

NPI: 1821674664
Provider Name (Legal Business Name): TAYLOR MADE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 W CHARLESTON BLVD
LAS VEGAS NV
89102-1835
US

IV. Provider business mailing address

3301 W CHARLESTON BLVD
LAS VEGAS NV
89102-1835
US

V. Phone/Fax

Practice location:
  • Phone: 702-800-0985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEEANN TAYLOR
Title or Position: MANAGER
Credential: DNP
Phone: 702-800-0985