Provider Demographics
NPI:1487725115
Name:LATIMER, GARY L (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:LATIMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 BROOKLYN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-2836
Mailing Address - Country:US
Mailing Address - Phone:570-282-1240
Mailing Address - Fax:570-282-7937
Practice Address - Street 1:267 BROOKLYN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2836
Practice Address - Country:US
Practice Address - Phone:570-282-1240
Practice Address - Fax:570-282-7937
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004100L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA590360OtherBLUE SHIELD ID #
PA2322827930OtherTAX ID #
PA590360OtherBLUE SHIELD ID #
PA583381Medicare UPIN