Provider Demographics
NPI:1275707424
Name:BRUCE V LATTYAK M.D., INC.
Entity Type:Organization
Organization Name:BRUCE V LATTYAK M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:V
Authorized Official - Last Name:LATTYAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-477-1199
Mailing Address - Street 1:300 SIERRA COLLEGE DR STE 240
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5086
Mailing Address - Country:US
Mailing Address - Phone:530-273-3400
Mailing Address - Fax:530-274-3400
Practice Address - Street 1:300 SIERRA COLLEGE DR STE 240
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5086
Practice Address - Country:US
Practice Address - Phone:530-273-3400
Practice Address - Fax:530-274-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62583207Y00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty