Healthcare Provider Details

I. General information

NPI: 1275836462
Provider Name (Legal Business Name): JARETT R TAYLOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2010
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E CHEVES ST
FLORENCE SC
29506-2617
US

IV. Provider business mailing address

PO BOX 100551
FLORENCE SC
29502-0551
US

V. Phone/Fax

Practice location:
  • Phone: 843-777-8752
  • Fax: 843-777-8705
Mailing address:
  • Phone: 843-777-8752
  • Fax: 843-777-8705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4414
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: