Provider Demographics
NPI:1104129261
Name:LATTERY, ALTON ROY SR
Entity type:Individual
Prefix:MR
First Name:ALTON
Middle Name:ROY
Last Name:LATTERY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 NW 115TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33167-2710
Mailing Address - Country:US
Mailing Address - Phone:305-687-7142
Mailing Address - Fax:305-687-7142
Practice Address - Street 1:2090 NW 115TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167-2710
Practice Address - Country:US
Practice Address - Phone:305-687-7142
Practice Address - Fax:305-687-7142
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility