=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366934135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LATENITE DISPATCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8560 CODY CT
-----------------------------------------------------
City | HUBER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45424-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-829-7341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5705 ROSEMONT CT
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-215-1714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | MS. LORETTA FLOYD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-829-7341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347E00000X
-----------------------------------------------------
Taxonomy Name | Transportation Broker
-----------------------------------------------------
License Number | HHC9818
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------