Provider Demographics
NPI:1497247407
Name:LATHAM, MAURICE TREVELLE SR
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:TREVELLE
Last Name:LATHAM
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 SUMMERSIDE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-6373
Mailing Address - Country:US
Mailing Address - Phone:757-927-2325
Mailing Address - Fax:
Practice Address - Street 1:928 SUMMERSIDE CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-6373
Practice Address - Country:US
Practice Address - Phone:757-927-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62676783343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)