Healthcare Provider Details

I. General information

NPI: 1740785823
Provider Name (Legal Business Name): LATAVEYA VAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 W MARKHAM ST STE 150
LITTLE ROCK AR
72205-1416
US

IV. Provider business mailing address

10025 W MARKHAM ST STE 150
LITTLE ROCK AR
72205-1416
US

V. Phone/Fax

Practice location:
  • Phone: 501-663-5473
  • Fax: 501-661-1812
Mailing address:
  • Phone: 501-663-5473
  • Fax: 501-661-1812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: