Provider Demographics
NPI:1538223854
Name:TAYLOR CLINIC LLC
Entity type:Organization
Organization Name:TAYLOR CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-649-7575
Mailing Address - Street 1:PO BOX 1566
Mailing Address - Street 2:212 JACKSON STREET
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-1566
Mailing Address - Country:US
Mailing Address - Phone:318-649-7575
Mailing Address - Fax:318-649-6878
Practice Address - Street 1:212 JACKSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-1566
Practice Address - Country:US
Practice Address - Phone:318-649-7575
Practice Address - Fax:318-649-6878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA194699261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA194699Medicare Oscar/Certification