Healthcare Provider Details

I. General information

NPI: 1649659699
Provider Name (Legal Business Name): LATITUDE 47 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27902 MOUND RD
HOCKLEY TX
77447-8295
US

IV. Provider business mailing address

27902 MOUND RD
HOCKLEY TX
77447-8295
US

V. Phone/Fax

Practice location:
  • Phone: 713-336-3419
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number102254
License Number StateTX

VIII. Authorized Official

Name: KELLEY WARREN
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: SLP-CCC
Phone: 713-336-3419