MEDICARE: LATAVEYA VAULT

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1740785823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATAVEYA VAULT

Provider Business Mailing Address
First Line	:	10025 W MARKHAM ST STE 150
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-1416
Country	:	US
Telephone Number	:	501-663-5473
Fax Number	:	501-661-1812

Provider Business Practice Location Address
First Line	:	10025 W MARKHAM ST STE 150
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-1416
Country	:	US
Telephone Number	:	501-663-5473
Fax Number	:	501-661-1812

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

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	03/29/2018

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Directions to “ LATAVEYA VAULT ” Practice Location

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