Provider Demographics
NPI:1215680905
Name:BREATH OF ELAN LLC
Entity type:Organization
Organization Name:BREATH OF ELAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DEVELOPMENT COORDINATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LATTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DHSC, MPAS, PA-C, CH
Authorized Official - Phone:281-967-3452
Mailing Address - Street 1:9212 FRY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-5487
Mailing Address - Country:US
Mailing Address - Phone:346-708-4587
Mailing Address - Fax:
Practice Address - Street 1:3619 QUARTER HORSE TRL
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-3571
Practice Address - Country:US
Practice Address - Phone:281-967-3452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date: