=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700093192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAYLOR REHABILITATION ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 10/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5750 ALEXIS RD
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-882-1841
-----------------------------------------------------
Fax | 419-882-1848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7733 NORTH BR
-----------------------------------------------------
City | MONCLOVA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43542-9376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-882-1841
-----------------------------------------------------
Fax | 419-882-1848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TIMOTHY S. TAYLOR
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 419-882-1841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 009404
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------