Basic Information
| Provider Information | |||||||||
| NPI: | 1942634431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | LATANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5882 MCASHAN RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MC CALLA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351114800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058217252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1686 MONTGOMERY HWY | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352164906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059792020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2013 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S-D05-TA-965 | AL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.