MEDICARE: LATITUDE, LLC

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	251C00000X	Developmentally Disabled Services Day Training Agency		KY

General Provider Information

NPI Number	:	1750420600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LATITUDE, LLC

Provider Business Mailing Address
First Line	:	167 SAUNIER ST
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40507-1251
Country	:	US
Telephone Number	:	859-806-0195
Fax Number	:	859-233-7927

Provider Business Practice Location Address
First Line	:	167 SAUNIER ST
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40507-1251
Country	:	US
Telephone Number	:	859-806-0195
Fax Number	:	859-233-7927

Authorized Official
Title or Position	:	MEDICAID DIVISION DIRECTOR
Name	:	MRS. CRYSTAL BADER
Credential	:
Telephone Number	:	859-806-0195

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	08/22/2020

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