MEDICARE: MR. WILLIE DARE TAYLOR ABOC,NCLEC,MBOC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	151016	MI

General Provider Information

NPI Number	:	1356780704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIE DARE TAYLOR ABOC,NCLEC,MBOC

Provider Business Mailing Address
First Line	:	723 RIVER PARK VILLAGE BLVD
Second Line	:	MOBILE UNIT DISPENSARY
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-2777
Country	:	US
Telephone Number	:	313-378-7883
Fax Number	:	248-465-9985

Provider Business Practice Location Address
First Line	:	723 RIVER PARK VILLAGE BLVD
Second Line	:	MOBILE UNIT DISPENSARY
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-2777
Country	:	US
Telephone Number	:	313-378-7883
Fax Number	:	248-465-9985

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2013
Last Update Date	:	06/19/2013

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