Healthcare Provider Details

I. General information

NPI: 1255477279
Provider Name (Legal Business Name): CAROLYN TAYLOR HUFF OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 BROAD STREET RD
MANAKIN SABOT VA
23103-2213
US

IV. Provider business mailing address

552 GLENMEADOW TER
MIDLOTHIAN VA
23114-3020
US

V. Phone/Fax

Practice location:
  • Phone: 804-784-3514
  • Fax: 804-784-4514
Mailing address:
  • Phone: 804-379-4741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0119002342
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: