MEDICARE: MRS. LATASHA A THOMAS-FULLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538367859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATASHA A THOMAS-FULLER

Provider Business Mailing Address
First Line	:	79 GUILFORD CT
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-7058
Country	:	US
Telephone Number	:	910-497-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 GUILFORD CT
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-7058
Country	:	US
Telephone Number	:	910-497-0002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2007
Last Update Date	:	08/05/2009

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