=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083081731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENTON LATTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2015
-----------------------------------------------------
Last Update Date | 11/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 AVALON DR
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-793-1957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 AVALON DR
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 30630
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070022132
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------