Healthcare Provider Details

I. General information

NPI: 1861905887
Provider Name (Legal Business Name): ANDREW KENNETH TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38882 MENTOR AVE
WILLOUGHBY OH
44094-7875
US

IV. Provider business mailing address

38882 MENTOR AVE
WILLOUGHBY OH
44094-7875
US

V. Phone/Fax

Practice location:
  • Phone: 440-953-9999
  • Fax: 440-918-3839
Mailing address:
  • Phone: 440-953-9999
  • Fax: 440-918-3839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: