Healthcare Provider Details

I. General information

NPI: 1548905417
Provider Name (Legal Business Name): TAYLOR VICTOR CAMELO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 ELM ST
BUFFALO NY
14203-1621
US

IV. Provider business mailing address

55 DODGE RD
GETZVILLE NY
14068-1205
US

V. Phone/Fax

Practice location:
  • Phone: 716-854-2444
  • Fax:
Mailing address:
  • Phone: 716-831-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number826047
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: