Healthcare Provider Details

I. General information

NPI: 1023154184
Provider Name (Legal Business Name): LATA S SHAH HIS NBC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S INDUSTRIAL DR STE 101
ORANGE CITY FL
32763-7421
US

IV. Provider business mailing address

123 S INDUSTRIAL DR STE 101
ORANGE CITY FL
32763-7421
US

V. Phone/Fax

Practice location:
  • Phone: 386-775-8960
  • Fax: 386-775-3757
Mailing address:
  • Phone: 386-775-8960
  • Fax: 386-775-3757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS2790
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: