Healthcare Provider Details

I. General information

NPI: 1942617303
Provider Name (Legal Business Name): CONNIE TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 CIRCLE DR
COLUMBIA TN
38401-4430
US

IV. Provider business mailing address

1615 WILLIAMSON DR
COLUMBIA TN
38401-5402
US

V. Phone/Fax

Practice location:
  • Phone: 931-490-1480
  • Fax:
Mailing address:
  • Phone: 931-981-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: