Healthcare Provider Details

I. General information

NPI: 1174067276
Provider Name (Legal Business Name): CARE OF LATRELLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 WAVERLY WAY
SAVANNAH GA
31407-5032
US

IV. Provider business mailing address

127 WAVERLY WAY
SAVANNAH GA
31407-5032
US

V. Phone/Fax

Practice location:
  • Phone: 912-220-8105
  • Fax:
Mailing address:
  • Phone: 912-220-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY DAVIS
Title or Position: CREDENTIALING SPECIALISTS
Credential:
Phone: 912-484-3879