Healthcare Provider Details

I. General information

NPI: 1316413511
Provider Name (Legal Business Name): TAYLOR MARIE LIFE LAT, ATC, PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 HOSPITALITY LN STE 3
MINERAL WELLS WV
26150-6705
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 304-489-8100
  • Fax: 304-489-8191
Mailing address:
  • Phone: 304-917-3660
  • Fax: 304-917-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT004688
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001684
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: