Provider Demographics
NPI:1861551814
Name:POLK, LATONYA
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:POLK
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:PO BOX 8664
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75607-8664
Mailing Address - Country:US
Mailing Address - Phone:903-315-8302
Mailing Address - Fax:903-297-4959
Practice Address - Street 1:205 E US HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:TX
Practice Address - Zip Code:75693-2103
Practice Address - Country:US
Practice Address - Phone:903-297-4959
Practice Address - Fax:903-297-4999
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251E00000XAgenciesHome Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities