Healthcare Provider Details

I. General information

NPI: 1023928165
Provider Name (Legal Business Name): TRUCKER'S LANE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 S MARTIN LUTHER KING JR AVE
SALISBURY NC
28144-5601
US

IV. Provider business mailing address

1740 S MARTIN LUTHER KING JR AVE
SALISBURY NC
28144-5601
US

V. Phone/Fax

Practice location:
  • Phone: 704-200-8751
  • Fax:
Mailing address:
  • Phone: 704-200-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LATASHA GIDDERON
Title or Position: OWNER/MANAGING MEMBER
Credential: CPSS
Phone: 704-200-8751