Provider Demographics
NPI:1538654199
Name:LATCH, JERRY WAYNE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:LATCH
Suffix:
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 1:206 N FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-5634
Mailing Address - Country:US
Mailing Address - Phone:662-286-8064
Mailing Address - Fax:662-286-8064
Practice Address - Street 1:206 N FILLMORE ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-286-8064
Practice Address - Fax:662-286-8064
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12758939332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies