Basic Information
| Provider Information | |||||||||
| NPI: | 1386781102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | LATANYA | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73194 SUN VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922772228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608191176 | ||||||||
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| Practice Location | |||||||||
| Address1: | 58945 BUSINESS CENTER DR STE D | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922847310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602289657 | ||||||||
| FaxNumber: | 7603696758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 09/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.