Provider Demographics
NPI:1023781390
Name:LATONIO, GARY (CDM MANAGER)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:LATONIO
Suffix:
Gender:M
Credentials:CDM MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14363 LORNE ST
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402
Mailing Address - Country:US
Mailing Address - Phone:818-268-8745
Mailing Address - Fax:
Practice Address - Street 1:14363 LORNE ST
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5207
Practice Address - Country:US
Practice Address - Phone:818-268-8748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-31
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170408132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager