Provider Demographics
NPI:1124433552
Name:RICHARD TAYLOR
Entity type:Organization
Organization Name:RICHARD TAYLOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-944-8565
Mailing Address - Street 1:1400 NE MIAMI GARDENS DR
Mailing Address - Street 2:202
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4845
Mailing Address - Country:US
Mailing Address - Phone:305-944-8565
Mailing Address - Fax:305-944-8388
Practice Address - Street 1:1400 NE MIAMI GARDENS DR
Practice Address - Street 2:202
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-4845
Practice Address - Country:US
Practice Address - Phone:305-944-8565
Practice Address - Fax:305-944-8388
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD TAYLOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-24
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034801173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065244000Medicaid
FL95383OtherMEDICARE PTAN
FLD64793Medicare UPIN