Healthcare Provider Details

I. General information

NPI: 1588299549
Provider Name (Legal Business Name): CRYSTAL LATIMER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 CYPRESS VILLAGE BLVD
SUN CITY CENTER FL
33573-6838
US

IV. Provider business mailing address

827 CYPRESS VILLAGE BLVD
SUN CITY CENTER FL
33573-6838
US

V. Phone/Fax

Practice location:
  • Phone: 813-633-0669
  • Fax: 813-633-0881
Mailing address:
  • Phone: 813-633-0669
  • Fax: 813-633-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: