Healthcare Provider Details

I. General information

NPI: 1649778820
Provider Name (Legal Business Name): RANDY TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VINE ST
SCRANTON PA
18510-2126
US

IV. Provider business mailing address

1101 VINE ST
SCRANTON PA
18510-2126
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-6177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: