=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134426844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER OF LIFE OSTEOPATHIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2011
-----------------------------------------------------
Last Update Date | 02/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2705 MAGUIRE RD
-----------------------------------------------------
City | OCOEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34761-4797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-574-2880
-----------------------------------------------------
Fax | 407-403-5612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2705 MAGUIRE RD
-----------------------------------------------------
City | OCOEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34761-4797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-574-2880
-----------------------------------------------------
Fax | 407-403-5612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | DR. RONALD WILLIAM TAYLOR JR.
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 407-739-6914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS9605
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------