Healthcare Provider Details

I. General information

NPI: 1013343219
Provider Name (Legal Business Name): CHARLOTTE LATHAM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 RIO GRANDE BLVD NW APT C
LOS RANCHOS NM
87114-1200
US

IV. Provider business mailing address

PO BOX 56843
ALBUQUERQUE NM
87187-6843
US

V. Phone/Fax

Practice location:
  • Phone: 505-231-4131
  • Fax:
Mailing address:
  • Phone: 505-231-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0889
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: