Provider Demographics
NPI:1609209642
Name:RAIFORD, LATONYA
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:RAIFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 PATRICK PLACE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-5613
Mailing Address - Country:US
Mailing Address - Phone:803-746-5154
Mailing Address - Fax:
Practice Address - Street 1:3023 PATRICK PLACE CIR
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-5613
Practice Address - Country:US
Practice Address - Phone:803-746-5154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC46-2929581OtherEIN