Healthcare Provider Details

I. General information

NPI: 1760971923
Provider Name (Legal Business Name): LATRENA M THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14091 SUMMER BREEZE DR E
JACKSONVILLE FL
32218-8913
US

IV. Provider business mailing address

PO BOX 77581
JACKSONVILLE FL
32226-7581
US

V. Phone/Fax

Practice location:
  • Phone: 804-502-5840
  • Fax: 904-485-8541
Mailing address:
  • Phone: 804-502-5840
  • Fax: 904-485-8541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number15IV043
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: