Provider Demographics
NPI:1699314765
Name:TAYLOR, JUSTIN J
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-3829
Mailing Address - Country:US
Mailing Address - Phone:218-283-2806
Mailing Address - Fax:
Practice Address - Street 1:2020 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-3829
Practice Address - Country:US
Practice Address - Phone:218-283-2806
Practice Address - Fax:218-283-2177
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN394505310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility