Healthcare Provider Details

I. General information

NPI: 1861551814
Provider Name (Legal Business Name): LATONYA POLK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E US HIGHWAY 80
WHITE OAK TX
75693-2103
US

IV. Provider business mailing address

PO BOX 8664
LONGVIEW TX
75607-8664
US

V. Phone/Fax

Practice location:
  • Phone: 903-297-4959
  • Fax: 903-297-4999
Mailing address:
  • Phone: 903-315-8302
  • Fax: 903-297-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: