Provider Demographics
NPI:1205293933
Name:LATORRE, TRISTAN
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:LATORRE
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 1:2751 MEANDERING TRL
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1015
Mailing Address - Country:US
Mailing Address - Phone:706-271-7197
Mailing Address - Fax:
Practice Address - Street 1:8450 WILL CLAYTON PKWY
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-5830
Practice Address - Country:US
Practice Address - Phone:281-446-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1259273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist