Provider Demographics
NPI:1366013823
Name:LANTANA PSYCHIATRY LLC
Entity Type:Organization
Organization Name:LANTANA PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-910-4144
Mailing Address - Street 1:1470 BEN SAWYER BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1470 BEN SAWYER BLVD STE 6
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4593
Practice Address - Country:US
Practice Address - Phone:843-352-9982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty