Healthcare Provider Details

I. General information

NPI: 1841880051
Provider Name (Legal Business Name): JOSHUA WOODWARD LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 EMERSON CUMMINGS BLVD
OLD ORCHARD BEACH ME
04064-1460
US

IV. Provider business mailing address

12 THORNTON AVE # 101
SACO ME
04072-2891
US

V. Phone/Fax

Practice location:
  • Phone: 207-391-3284
  • Fax:
Mailing address:
  • Phone: 207-391-3284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT702
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: