Healthcare Provider Details

I. General information

NPI: 1528840428
Provider Name (Legal Business Name): LATECKA S MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 E MONTGOMERY XRD
SAVANNAH GA
31406-4730
US

IV. Provider business mailing address

147 E MONTGOMERY XRD
SAVANNAH GA
31406-4730
US

V. Phone/Fax

Practice location:
  • Phone: 912-201-1701
  • Fax:
Mailing address:
  • Phone: 912-201-1701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO133923
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCO133923
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCO133923
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberCO133923
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: