Basic Information
| Provider Information | |||||||||
| NPI: | 1053729889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | BROOKS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | FLAGLER BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321363484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865693346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 515 PALM COAST PKWY SW | ||||||||
| Address2: | SUITE 6/7 | ||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321374739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869513044 | ||||||||
| FaxNumber: | 8666100580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2014 | ||||||||
| LastUpdateDate: | 08/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.