Healthcare Provider Details

I. General information

NPI: 1962275834
Provider Name (Legal Business Name): HALEIGH LATHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8144 ESCONDIDO CANYON RD
ACTON CA
93510-1534
US

IV. Provider business mailing address

PO BOX 221510
SANTA CLARITA CA
91322-1510
US

V. Phone/Fax

Practice location:
  • Phone: 661-255-7963
  • Fax:
Mailing address:
  • Phone: 661-255-7963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: