Healthcare Provider Details

I. General information

NPI: 1871463380
Provider Name (Legal Business Name): LATRELL WADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3052 BARDSTOWN RD
LOUISVILLE KY
40205-3020
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 502-454-5544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP051580T
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: