Healthcare Provider Details

I. General information

NPI: 1508457888
Provider Name (Legal Business Name): TAYLER WADDELL LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 ROYAL AVE
MEDFORD OR
97504-6140
US

IV. Provider business mailing address

1744 E MCANDREWS RD STE D
MEDFORD OR
97504-5576
US

V. Phone/Fax

Practice location:
  • Phone: 541-414-0362
  • Fax: 541-200-2262
Mailing address:
  • Phone: 541-414-0362
  • Fax: 541-200-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19652
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: