MEDICARE: TAYLOR VISTAD

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	390200000X	Student in an Organized Health Care Education/Training Program		ND

General Provider Information

NPI Number	:	1710597091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR VISTAD

Provider Business Mailing Address
First Line	:	1220 5TH AVE NE
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-1934
Country	:	US
Telephone Number	:	701-739-6262
Fax Number	:

Provider Business Practice Location Address
First Line	:	1220 5TH AVE NE
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-1934
Country	:	US
Telephone Number	:	701-739-6262
Fax Number	:

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

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	08/03/2020

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Directions to “ TAYLOR VISTAD ” Practice Location

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