1174869010 NPI number — MR. BRYCE KENDALL TAYLOR LPCA

Table of content: MR. BRYCE KENDALL TAYLOR LPCA (NPI 1174869010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174869010 NPI number — MR. BRYCE KENDALL TAYLOR LPCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
BRYCE
Provider Middle Name:
KENDALL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPCA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174869010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
284 EXECUTIVE PARK DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28025-1833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-939-1100
Provider Business Mailing Address Fax Number:
704-939-1173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 W ROOSEVELT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28110-2818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-296-6200
Provider Business Practice Location Address Fax Number:
704-296-4668
Provider Enumeration Date:
12/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  9315 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19L2X . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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