Healthcare Provider Details

I. General information

NPI: 1770627440
Provider Name (Legal Business Name): MICHAEL R. LAND D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12831 6TH ST SUITE C&D
LILLIAN AL
36549-4166
US

IV. Provider business mailing address

12831 6TH ST SUITE C&D
LILLIAN AL
36549-4166
US

V. Phone/Fax

Practice location:
  • Phone: 251-962-2149
  • Fax: 251-961-3815
Mailing address:
  • Phone: 251-962-2149
  • Fax: 251-961-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH3908
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: