=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891453353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIARA LATZ DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2021
-----------------------------------------------------
Last Update Date | 02/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18924 LAKE DR E
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-474-1949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18924 LAKE DR E
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-474-1949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6917
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------