Provider Demographics
NPI:1205539665
Name:TAYLOR, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
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 1:7758 WICK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBOURNE
Mailing Address - State:WV
Mailing Address - Zip Code:26149-7502
Mailing Address - Country:US
Mailing Address - Phone:304-482-2940
Mailing Address - Fax:
Practice Address - Street 1:7758 WICK RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBOURNE
Practice Address - State:WV
Practice Address - Zip Code:26149-7502
Practice Address - Country:US
Practice Address - Phone:304-482-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker