Provider Demographics
NPI:1730786070
Name:TAYLOR, CHARLES THADDIOUS JR (LPN)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:THADDIOUS
Last Name:TAYLOR
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 CHILI AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-2604
Mailing Address - Country:US
Mailing Address - Phone:585-351-1003
Mailing Address - Fax:
Practice Address - Street 1:115 CHILI AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-2604
Practice Address - Country:US
Practice Address - Phone:585-351-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339455-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse