Healthcare Provider Details

I. General information

NPI: 1316286156
Provider Name (Legal Business Name): RANDOLPH HAYES LATIMORE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W BASS ST
KISSIMMEE FL
34741-5011
US

IV. Provider business mailing address

311 W BASS ST
KISSIMMEE FL
34741-5011
US

V. Phone/Fax

Practice location:
  • Phone: 407-870-5959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305207025
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: