MEDICARE: LATCH LADIES, 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	163WL0100X	Lactation Consultant (Registered Nurse)

General Provider Information

NPI Number	:	1780221069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LATCH LADIES, LLC

Provider Business Mailing Address
First Line	:	6416 LANSDALE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-1624
Country	:	US
Telephone Number	:	817-456-1217
Fax Number	:

Provider Business Practice Location Address
First Line	:	6416 LANSDALE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-1624
Country	:	US
Telephone Number	:	817-456-1217
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SALLY DAVIDSON ZUKOSKI
Credential	:	RN, IBCLC
Telephone Number	:	817-456-1217

Provider Enumeration Date	:	12/05/2019
Last Update Date	:	12/05/2019

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