Provider Demographics
NPI:1669841458
Name:LATITUDE 19 MEDICAL INC.
Entity Type:Organization
Organization Name:LATITUDE 19 MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-237-0590
Mailing Address - Street 1:75-5737 KUAKINI HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1725
Mailing Address - Country:US
Mailing Address - Phone:808-640-3460
Mailing Address - Fax:
Practice Address - Street 1:75-5591 PALANI RD
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3631
Practice Address - Country:US
Practice Address - Phone:808-640-3460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-685261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center