Healthcare Provider Details

I. General information

NPI: 1649768003
Provider Name (Legal Business Name): ZACKARY KEEN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6169B HERON AVE
EWA BEACH HI
96706-3341
US

IV. Provider business mailing address

6169B HERON AVE
EWA BEACH HI
96706-3341
US

V. Phone/Fax

Practice location:
  • Phone: 386-600-2810
  • Fax:
Mailing address:
  • Phone: 386-600-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL5236
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: