Provider Demographics
NPI:1528840428
Name:MOORE, LATECKA S
Entity type:Individual
Prefix:
First Name:LATECKA
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 E MONTGOMERY XRD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4730
Mailing Address - Country:US
Mailing Address - Phone:912-201-1701
Mailing Address - Fax:
Practice Address - Street 1:147 E MONTGOMERY XRD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4730
Practice Address - Country:US
Practice Address - Phone:912-201-1701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1339231744P3200X, 224P00000X, 225000000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty