MEDICARE: MRS. VIRGINIA RENEE LATTUS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT5883	TN

General Provider Information

NPI Number	:	1215936760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VIRGINIA RENEE LATTUS PT

Provider Business Mailing Address
First Line	:	5028 OLD PIERCE RD
Second Line	:
City	:	SOUTH FULTON
State	:	TN
Zip	:	38257-8108
Country	:	US
Telephone Number	:	731-884-0744
Fax Number	:	731-884-0748

Provider Business Practice Location Address
First Line	:	1720 E REELFOOT AVE
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-6047
Country	:	US
Telephone Number	:	731-884-0744
Fax Number	:	731-884-0748

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/08/2007

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