Provider Demographics
NPI:1558840298
Name:LATTA, KENNETH LEE (PTA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:LATTA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W GOODWIN AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:169 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PEARSALL
Practice Address - State:TX
Practice Address - Zip Code:78061-6604
Practice Address - Country:US
Practice Address - Phone:830-334-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2018479225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant