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General NPI Number Information
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NPI Number | 1174738520
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Entity Type | Organization
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Legal Business Name | LAKE NORMAN INTEGRATIVE PSYCHIATRY
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 10/03/2007
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Provider Practice Location Address
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Address Line | 116 S MAIN ST STE 301
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City | MOORESVILLE
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State | NC
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Zip | 28115-2373
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Country | US
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Telephone | 704-662-3200
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Fax | 704-662-1247
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Provider Business Mailing Address
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Address Line | 116 S MAIN ST STE 301 P.O. BOX 1247
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City | MOORESVILLE
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State | NC
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Zip | 28115-2373
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Country | US
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Telephone | 704-662-3200
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Fax | 704-662-8731
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Authorized Official
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Title or Position | SOLE OWNER
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Name | DR. TRACY THOMPSON LATZ
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Credential | M.D., M.S.
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Telephone | 704-662-3200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 34660
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License Number State | NC
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