=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063655751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAYLOR TOUCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2009
-----------------------------------------------------
Last Update Date | 04/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 WOODLAWN AVE
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-2196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-239-9973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2418 CARMATHEN RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-0984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-239-9973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. SHANTAY MAURICE TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-239-9973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------